{"id":516,"title":"CLAIM FORM FOR FIDELITY GUARANTEE 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-fidelity-guarantee-insurance-retail.pdf","sha256":"bbd0f4f2907c98a2884445aae8918fa1106dce4fe19e62312d2ee941d77734f5","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to file a claim under the Fidelity Guarantee Insurance policy for losses caused by employee defalcation.","notes":["Attach additional signed sheet if space is insufficient to describe defalcation","Attach certified statement of book entries related to defalcation","Use original blank cancelled cheque and PAN card copy for EFT mandate","Follow claim intimation and document submission instructions carefully","The form is not an admission of liability by the insurer"],"title":"CLAIM FORM FOR FIDELITY GUARANTEE INSURANCE","submit":{"to":"assigned Claims Manager (CSM) / Surveyor","how":"submit documents to the assigned CSM/Surveyor","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Defaulting Employee","fields":[{"help":"","type":"text","label":"Name of the defaulting employee in full","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"His present address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"","type":"amount","label":"Amount of loss sustained","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss was discovered","type":"date","label":"Date of discovery of the loss","options":[],"required":null,"pdf_field":""},{"help":"Date or dates when the loss occurred","type":"date","label":"Date(s) of loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Defalcation","fields":[{"help":"Describe the method of defalcation in detail; attach additional sheet and certified statement if needed","type":"text","label":"How exactly was the defalcation committed? If space is not sufficient, please give full and detailed particulars on a separate signed sheet. (Also please attach a certified statement containing all entries in the Insured's books of accounts relative to the defalcation in the order of their dates).","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Duties at Time of Defalcation","fields":[{"help":"Describe employee's role and location","type":"text","label":"In what capacity was he engaged and where?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"How did the money reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Specify amount and duration","type":"amount","label":"What was the largest sum that he held in his hands at any one time and for how long?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was he allowed to pay out any amounts on the Insured's behalf?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name or designation of authoriser","type":"text","label":"Who authorised these payments?","options":[],"required":null,"pdf_field":""},{"help":"Explain receipt and checking process","type":"text","label":"Was he required to give printed receipts from a book with counterfoils? If so, how often were the counterfoils examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Describe bank deposit and verification process","type":"text","label":"Were moneys paid into Bank by the defaulting employee? If so, how often were Bank Books examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"What balance, if any, was allowed to be kept in his hand?","options":[],"required":null,"pdf_field":""},{"help":"Describe cash account reconciliation process","type":"text","label":"How often were the Cash Accounts balanced and how was their accuracy checked? Please explain fully","options":[],"required":null,"pdf_field":""},{"help":"Frequency of independent account dispatch","type":"text","label":"How often were accounts sent direct to Customers independently of the employee?","options":[],"required":null,"pdf_field":""},{"help":"Explain stock handling by employee","type":"text","label":"Did the employee have charge of stock? If so, in what way did stock reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"Describe authorization for stock issuance","type":"text","label":"Was he allowed to issue stores or materials independently? If not, who authorised these issues?","options":[],"required":null,"pdf_field":""},{"help":"Frequency of stock checks","type":"text","label":"How often was the position of stock handled by the employee checked?","options":[],"required":null,"pdf_field":""},{"help":"Date of last stock check","type":"date","label":"When was the last check made?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Audit and Security Details","fields":[{"help":"Provide audit frequency, auditor name, and last audit date","type":"text","label":"How often Account Book/ Stock Books were audited and by whom? When was the last audit done?","options":[],"required":null,"pdf_field":""},{"help":"List any assets held from employee","type":"text","label":"Has the Insured any moneys, estate, or effects of the employee in his possession? If so, give particulars with amounts.","options":[],"required":null,"pdf_field":""},{"help":"Describe other securities held","type":"text","label":"Does the Insured hold any other security from the employee? If so, state its nature and amount.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Personal Details","fields":[{"help":"Provide details of family or property","type":"text","label":"Is the defaulting employee a member of a joint family, or does he hold any property furniture or other effects? If so, give details.","options":[],"required":null,"pdf_field":""},{"help":"List names and addresses of relatives","type":"text","label":"Has the employee any near relatives? If so, give their names and addresses, if known.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Actions Taken","fields":[{"help":"Describe any disciplinary or legal action","type":"text","label":"Has the Insured taken any action against the employee? If so, state the nature of action taken.","options":[],"required":null,"pdf_field":""},{"help":"Provide enquiry details and outcome","type":"text","label":"Has the Insured initiated Departmental Enquiry against the Employee? If so, state the outcome of the same.","options":[],"required":null,"pdf_field":""},{"help":"Provide police station name and actions taken","type":"text","label":"Has the loss been reported to the Police? If so, state at which Police Station and what action was taken by Police.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide any other details relevant to the claim","type":"text","label":"Any other relevant information.","options":[],"required":false,"pdf_field":""},{"help":"List other insurance policies covering this risk","type":"text","label":"Details of other insurance covering same risk","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":null,"pdf_field":""},{"help":"Provide relationship and position 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":"insured"},{"title":"Declarations and Signature","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 the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate Form","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":"Name as per bank records","type":"text","label":"If yes, kindly provide the below mentioned details : Payee Name (as per bank records):","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account: Savings / Current / Others (specify):","options":["Savings","Current","Others"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank :","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name :","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"IFSC code for electronic transfer","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"PAN card number","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":null,"pdf_field":""},{"help":"Attach original cancelled cheque","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":"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":"Fidelity Guarantee Insurance claims","attachments":["certified statement containing all entries in the Insured's books of accounts relative to the defalcation in the order of their dates","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 or policy endorsement","No material information relevant to the claim has been withheld or not disclosed","False or fraudulent statements or suppression of material information will void the policy and claim rights","Receipt of claim form or documents does not constitute admission of claim liability","Consent is given to verify identity/address proof through Central KYC Registry or 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/516-claim-form-for-fidelity-guarantee-insurance"}