{"id":514,"title":"CLAIM FORM PREMISES POLLUTION LIABILITY 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/28-pollution-premises-liability-retail8c0007ff45fd68ff8a0df0055faee33a.pdf","sha256":"53f1282bbf1ed9501d9e2490a851307e3b531da84d4e80a5c517f047a1f3106b","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for insured persons to report and claim under their Premises Pollution Liability Insurance policy with ICICI Lombard General Insurance Company Limited.","notes":["Attach all relevant documents as listed in the form.","File an FIR if applicable for third-party property damage or bodily injury.","A licensed surveyor will be appointed within 24 hours of claim reporting.","Assessment report will be furnished within 15 days of receipt of claim form and documents.","Claim decision will be made within 7 days of receipt of assessment report.","Use original documents and provide clear photographs or videos of damaged property.","Keep the claim reference number for future correspondence."],"title":"CLAIM FORM PREMISES POLLUTION LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited via toll-free no.: 1800 2666, Email ID: customersupport@icicilombard.com, or website https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx","how":"post / e-mail / upload via website","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"Specify the type of cover, e.g. Kidnap and ransom insurance","type":"text","label":"Type of Cover:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy period","type":"text","label":"Policy period","options":[],"required":null,"pdf_field":""},{"help":"Start date of policy period (DD/MM/YYYY)","type":"date","label":"From","options":[],"required":null,"pdf_field":""},{"help":"End date of policy period (DD/MM/YYYY)","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Enter the retroactive date if applicable","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the sum insured limit","type":"amount","label":"Limit (sum Insured)","options":[],"required":null,"pdf_field":""},{"help":"Enter the deductible amount","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss-causing event occurred (DD/MM/YYYY)","type":"date","label":"Date of Occurrence of Circumstances leading to loss","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimate of the claim amount","type":"amount","label":"Estimated amount of claim:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Describe the claim in detail","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the jurisdiction affected by the claim","type":"text","label":"Jurisdiction affected","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of the alleged kidnapping","type":"text","label":"The nature of the alleged kidnapping","options":[],"required":null,"pdf_field":""},{"help":"Date when the alleged kidnapping was committed (DD/MM/YYYY)","type":"date","label":"The date it was committed,","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of the alleged damage","type":"text","label":"The nature of the alleged damage,","options":[],"required":null,"pdf_field":""},{"help":"List the names of all claimants","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List the defendants involved","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering the same risk","type":"text","label":"Details of Other Insurance covering same risk","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any applicant is a Politically Exposed Person or related","type":"yes-no","label":"Are you or any of the proposed applicants a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details about the PEP relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""},{"help":"Describe the chain of events in chronological order; attach separate pages if required","type":"text","label":"Chain of Events (in chronological date wise)","options":[],"required":false,"pdf_field":""},{"help":"Provide the current status of legal or claim proceedings","type":"text","label":"Status of proceedings as on Date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Enter the place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing (DD/MM/YYYY)","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the authorised signatory","type":"signature","label":"Authorised Signatory","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Premises Pollution Liability Insurance claims","attachments":["Copy of the legal notice/Written Intimation received by the insured","Any legal opinion considered by the insured","Copy of the complete correspondence till date"],"declarations":["The insured must provide all information and cooperation reasonably required by the insurer.","The insured agrees not to settle or admit liability for any claim without the insurer’s prior written consent.","Consent is given to the company to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC purposes."],"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/514-claim-form-premises-pollution-liability-insurance"}