{"id":508,"title":"Business Prime Policy Claim Form","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/claim-form-for-business-prime-policy.pdf","sha256":"a44e801117f60c47bc94e5d067f6788f291b6cacfa1d64ddf9dc8ebf97b050be","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage under the Business Prime Policy.","notes":["Answer all questions fully.","This form is not an admission of liability.","Attach copies of other insurance policies if applicable.","Politically Exposed Persons (PEPs) definition is provided for reference."],"title":"Business Prime Policy Claim Form","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No.16, New Link Road Malad (W), Mumbai - 400 064"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Policy Number","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Other Insurance","fields":[{"help":"Attach copies of such policies if insurance is effected with other companies.","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s)","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Co-insurance %","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Loss","fields":[{"help":"Provide the exact time and date when the loss occurred.","type":"date","label":"Time & Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the cause of the loss.","type":"text","label":"Cause of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the item(s) affected under the policy.","type":"text","label":"Item of Policy affected (give description)","options":[],"required":true,"pdf_field":""},{"help":"State the use or occupation of the premises when the loss happened.","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":true,"pdf_field":""},{"help":"Indicate if the fire brigade was informed and reasons if not.","type":"yes-no","label":"Has the Loss been reported to Fire Brigade? (If applicable, give reason for non-intimation)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if the police were informed and reasons if not.","type":"yes-no","label":"Has the Loss been reported to Police? (If not, give reasons)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Loss Details","fields":[{"help":"Provide the location for inspection of the loss.","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""},{"help":"Describe the extent of the loss in detail.","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":true,"pdf_field":""},{"help":"Provide any other relevant information for claim processing.","type":"text","label":"Any additional information relevant to processing of Claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Persons (PEP) Declaration","fields":[{"help":"Select Yes or No.","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs *?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered Yes above.","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Enter the place where the form is signed.","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of signing.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form here.","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Business Prime Policy","attachments":["Copies of other insurance policies if insurance is effected with other companies"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal 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.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this claim form does not constitute admission of liability by the company.","Consent is given to verify identity and address proof through Central KYC Registry, UIDAI or other modes for KYC."],"dropped_labels":1},"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/508-business-prime-policy-claim-form"}