{"id":512,"title":"CLAIM FORM FOR MONEY 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/claim-form-for-money-insurance-retail.pdf","sha256":"4f5062c81b2ee7e40fa7137031e6b0c2236a406e02749cf901c867507bf09a19","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person to claim money insurance for loss of money either kept in safe or in transit.","notes":["Use original bills and documents only.","Attach all relevant documents as listed.","Sign the form and provide date and place.","For Electronic Fund Transfer, attach original cancelled cheque and PAN card copy.","The form issuance is not an admission of liability.","Follow claim intimation and surveyor appointment process as described.","The terms and conditions for RTGS/NEFT payments apply as stated."],"title":"CLAIM FORM FOR MONEY INSURANCE","submit":{"to":"Connect via Toll-free no.: 1800 2666, Email ID: customersupport@icicilombard.com, or website https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx","how":"Register claim online and submit claim related documents along with claim form","address":""},"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":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"","type":"choice","label":"Did the loss occur when the money was kept in safe or whilst in transit?","options":["In Safe","In Transit"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"In whose custody was the money at the time of loss?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the money carried with an armed guard?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe other security measures","type":"text","label":"Any other protection provided?","options":[],"required":null,"pdf_field":""},{"help":"Describe the carrying method","type":"text","label":"How was the money being carried?","options":[],"required":null,"pdf_field":""},{"help":"Specify mode of transport","type":"text","label":"Means of transport","options":[],"required":null,"pdf_field":""},{"help":"Explain how the loss happened","type":"text","label":"Give the circumstances of loss","options":[],"required":null,"pdf_field":""},{"help":"Specify the claimed loss amount","type":"amount","label":"What is the amount of loss?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide FIR or complaint details","type":"text","label":"Have you informed the Police Authorities? Details of the C.R. No & name of the Police Station.","options":[],"required":null,"pdf_field":""},{"help":"Describe recovery efforts","type":"text","label":"Steps taken to recover the lost money","options":[],"required":null,"pdf_field":""},{"help":"Provide details and attach documents","type":"text","label":"Whether any employee(s) has/have been involved in the incident? If so, the details of the action taken against him/ them like Police complaint, Departmental enquiry etc. (Please attach copies of documents)","options":[],"required":null,"pdf_field":""},{"help":"Provide other insurance details","type":"text","label":"Is there any other insurance upon the same money? If so give full particulars.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever before sustained loss of the same nature?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide policy details if applicable","type":"text","label":"Whether persons carrying money were covered under Fidelity Guarantee policy? If yes, details of the policy & issuing office.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Details of other insurance covering same risk","options":[],"required":false,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? Yes No If yes, please give details (Nature of relationship and position held by PEP):","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Clause / Settlement of Claim","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 here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","fields":[{"help":"","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","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":"","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"Attach PAN card copy","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":null,"pdf_field":""},{"help":"Mandatory","type":"attachment","label":"Attach an Original Blank Cancelled Cheque signed by the Payee.","options":[],"required":true,"pdf_field":""},{"help":"Mandatory","type":"attachment","label":"Attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"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":"Money insurance claims","attachments":["Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim, for instance, Service Engineer’s Report, Fire Brigade Report, etc.","FIR / Final Police investigation report wherever applicable","Repair/ replacement quotation, invoice and payment proofs for each and every item as claimed (if items to be repaired or reinstated)","Documents substantiating the quantum & value of the items under claim (if items not to be 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","Any other document which may be specified by the surveyor post completion of initial survey","Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee"],"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 proposal form or policy endorsement.","No material information relevant to claim processing has been withheld or not disclosed.","False or fraudulent statements or suppression of material information will void the policy and claims.","Receipt of claim form or documents does not constitute admission of claim liability by the company.","Consent is given to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC."],"dropped_labels":7},"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/512-claim-form-for-money-insurance"}