{"id":507,"title":"CLAIM FORM FOR ICICI LOMBARD FIRE AND ALLIED PERILS INSURANCE POLICY","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/icici-lombard-fire-and-allied-perils-insurance-policy.pdf","sha256":"a07327a22a07b85b0944f907ec0c3ed0aebc05cd67a9764621e3b397b122a05b","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage under the ICICI Lombard Fire and Allied Perils Insurance Policy.","notes":["The insurance policy is a contract of indemnity; claims must be based on actual value of goods at time of loss excluding any profit.","Please answer all questions fully.","Attach copies of other insurance policies if applicable."],"title":"CLAIM FORM FOR ICICI LOMBARD FIRE AND ALLIED PERILS INSURANCE POLICY","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400064"},"purpose":"claim","sections":[{"title":"DETAILS OF INSURED","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF OTHER INSURANCE","fields":[{"help":"If insurance is effected with other companies, attach copies of such policies.","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured (INR)","options":[],"required":null,"pdf_field":""},{"help":"Start date of the other insurance policy","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"End date of the other insurance policy","type":"date","label":"To","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF LOSS","fields":[{"help":"Specify the exact time and date when the loss occurred","type":"date","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of the loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the affected insured item","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"State the use or occupation of the premises when loss occurred","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate yes or no and reasons if not reported","type":"text","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":[],"required":null,"pdf_field":""},{"help":"Indicate yes or no and reasons if not reported","type":"text","label":"Has the Fire / Loss been reported to Police? (If not, give reasons)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"LOSS INSPECTION AND EXTENT","fields":[{"help":"Provide the location address for inspection","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe the extent of the loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF CLAIM FOR PROPERTY DESTROYED OR DAMAGED","fields":[{"help":"List item number as per policy","type":"text","label":"Item No. of Policy","options":[],"required":null,"pdf_field":""},{"help":"Describe the property affected by fire","type":"text","label":"Description of affected Property","options":[],"required":null,"pdf_field":""},{"help":"State the value of the property at time of loss","type":"amount","label":"Value at the time of Fire Rs.","options":[],"required":null,"pdf_field":""},{"help":"Deduct salvage value if any","type":"amount","label":"Deduction for Value of Salvage Rs.","options":[],"required":null,"pdf_field":""},{"help":"Net claim amount after salvage deduction","type":"amount","label":"Net Amount Claimed Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION AND SIGNATURE","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Fire and allied perils insurance claims","attachments":["Copies of other insurance policies if insurance is effected with other companies"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal form or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or concealed.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not constitute admission of liability by the company."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/507-claim-form-for-icici-lombard-fire-and-allied-perils-insurance-policy"}