{"id":511,"title":"CLAIM FORM FOR PLATE GLASS INSURANCE","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/plate-glass-insurance-retail.pdf","sha256":"fbb647f2576a7944bed3cadf340e60ff7022c352cb4af14cff9cbef6f525116a","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders to notify and claim for physical loss or damage under their Plate Glass Insurance policy.","notes":["Use original bills and documents as specified","Attach all required documents including FIR copy and photographs","Submission of documents or bank details does not imply admission of liability","For Electronic Fund Transfer, attach original cancelled cheque and PAN card copy","Terms and conditions for RTGS/NEFT payments apply as stated in the form"],"title":"CLAIM FORM FOR PLATE GLASS INSURANCE","submit":{"to":"Assigned Claims Manager (CSM) or Surveyor","how":"Submit claim form and documents via toll-free number, email, or website claim portal as per instructions","address":"https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx; Email: customersupport@icicilombard.com; Toll-free no.: 1800 2666"},"purpose":"claim","sections":[{"title":"Details of Insured and Loss","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation:","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":"Describe the type of loss or damage.","type":"text","label":"Nature of loss/ damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the damaged property.","type":"text","label":"Details of damaged property","options":[],"required":null,"pdf_field":""},{"help":"Specify the location of the loss.","type":"text","label":"Place & address where the loss took place.","options":[],"required":null,"pdf_field":""},{"help":"Provide last known location and time of missing property.","type":"text","label":"When and where was the missing property last seen?","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of discovery of loss.","type":"date","label":"Date and time when loss was first discovered.","options":[],"required":null,"pdf_field":""},{"help":"Explain how the loss or damage occurred.","type":"text","label":"State the circumstances of the loss or damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated monetary value.","type":"amount","label":"Estimated value of items lost or Damaged","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of police report.","type":"date","label":"Date and time of reporting the loss to Police Station.","options":[],"required":null,"pdf_field":""},{"help":"Provide police station details.","type":"text","label":"Name and address of the Police Station.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you the sole owner of the property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Have you ever before sustained loss of the same nature? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if any.","type":"text","label":"Is there any other insurance on the same property? If so, give full particulars","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant information.","type":"text","label":"Any additional information relevant to processing of claim","options":[],"required":false,"pdf_field":""},{"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 PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Electronic Fund Transfer Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name as per bank records.","type":"text","label":"Payee Name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account number.","type":"text","label":"Payee Account No.","options":[],"required":null,"pdf_field":""},{"help":"Select account type or specify if others.","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":null,"pdf_field":""},{"help":"Provide bank name.","type":"text","label":"Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Provide branch name.","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Provide bank branch address.","type":"text","label":"Address of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Provide IFSC code.","type":"text","label":"IFSC Code No. of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Provide MICR code if available.","type":"text","label":"MICR Code No. of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN number.","type":"text","label":"Permanent Account Number (PAN) of Payee","options":[],"required":null,"pdf_field":""},{"help":"Attach original cancelled cheque with signature.","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy.","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declarations and Signature","fields":[{"help":"Enter place of signing.","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing.","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign the form.","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Assessment sheet / Survey report will be furnished within 15 days of receipt of claim form and documents","Claim will be decided within 7 days of receipt of the assessment sheet / survey report"],"applies_to":"Plate Glass Insurance claims","attachments":["Copy of FIR","Photographs / Video of damaged property/item under claim","Service Engineer’s Report, Fire Brigade Report, etc. (if applicable)","FIR / Final Police investigation report (if applicable)","Repair/ replacement quotation, invoice and payment proofs for each item claimed","Documents substantiating the quantum & value of items under claim (if not repaired or reinstated)","Offer for retention of salvage (if any)","KYC / NEFT Details as per AML guidelines","Invoice copy / Goods Receipt Note / Monetary Claim on carrier / Damage Certificate","Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"declarations":["The information given in this claim form is true, correct and complete","All persons having interest in the property are disclosed as per policy","No material information relevant to claim processing has been withheld","False or fraudulent statements will void the policy and claims","Receipt of claim form or documents does not imply admission of claim liability","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes"],"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/511-claim-form-for-plate-glass-insurance"}