{"id":515,"title":"CLAIM FORM EMPLOYMENT PRACTICES 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/employment-practices-liability-retail.pdf","sha256":"fccbfecba69d95b69045f73d8273fdd809673451b9408ff4266b3f1d7309ce4d","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim under the Employment Practices Liability Insurance policy for losses arising from employment-related claims.","notes":["The insured must provide information and cooperation as reasonably required by the insurer.","No settlement, legal costs, or admission of liability can be made without the insurer's prior written consent.","Claim intimation is without prejudice and insurer's rights are reserved.","File an FIR if applicable as per policy terms.","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting.","Assessment and survey report turnaround time is 15 days; claim decision within 7 days after assessment.","Submit original and relevant documents as listed to support the claim.","Use the claim reference number for all future correspondence."],"title":"CLAIM FORM EMPLOYMENT PRACTICES LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited via Claims Manager or Surveyor","how":"upload via website, email, or as directed by Claims Manager/Surveyor","address":"Email: customersupport@icicilombard.com; Website: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx; Toll-free no.: 1800 2666"},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Start date of the policy period","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Maximum amount payable under the policy","type":"amount","label":"Limit Of Liability","options":[],"required":null,"pdf_field":""},{"help":"Amount to be borne by the insured before insurer liability","type":"amount","label":"Retention","options":[],"required":null,"pdf_field":""},{"help":"Specify if Cyber Liability cover is included","type":"text","label":"Cyber Liability","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":"Where the claim event occurred","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Explain the wrongful act alleged","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or incident occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage caused by the wrongful act","type":"text","label":"The nature of the alleged damage","options":[],"required":null,"pdf_field":""},{"help":"List all claimants involved","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List defendants related to the claim","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","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 answer above is Yes","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":"Additional Claim Information","fields":[{"help":"Provide estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the sequence of events related to the claim","type":"text","label":"Chronology of Events","options":[],"required":null,"pdf_field":""},{"help":"Current status of any legal or other proceedings","type":"text","label":"Status of proceedings as on date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, specify type of cover","type":"text","label":"Type of Cover","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Name of insured under other insurance","type":"text","label":"Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of other policy period","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Name of the insured entity or person signing","type":"text","label":"For and on Behalf of","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized signatory","type":"signature","label":"Authorised Signatory","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Employment Practices 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","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for each item claimed","Documents substantiating the quantum & value of items under claim 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 specified by the surveyor post completion of initial survey"],"declarations":["The information furnished in this Claim Intimation Form is true, correct and complete to the best of the insured's knowledge.","Any untrue or false statement or concealment of material facts will forfeit the right to claim under the policy.","The insured consents and authorizes the insurer to seek necessary information/documents from any third party who has made the claim.","The insured consents to the insurer verifying identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes."],"dropped_labels":5},"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/515-claim-form-employment-practices-liability-insurance"}