{"id":518,"title":"CLAIM FORM FOR BURGLARY 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-burglary-insurance-commercial.pdf","sha256":"998b9ef8a8225db66b2fe4f3fa01d49539b185a54f8bcda55588734dd9194465","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person to notify and claim for physical loss or damage due to burglary under their insurance policy.","notes":["Attach a copy of the police complaint with the form.","The Direct Fund Transfer/EFT Mandate Form details are mandatory if opting for electronic payment.","Terms and conditions for RTGS/NEFT payments apply as stated in the form.","Submission of documents or bank details does not imply admission of liability by the company."],"title":"CLAIM FORM FOR BURGLARY INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured and Loss","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the insured","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid phone number","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"Provide the exact location where the loss happened","type":"text","label":"State the address of premises at which the loss occurred.","options":[],"required":null,"pdf_field":""},{"help":"Describe the occupancy status of the premises","type":"text","label":"How was the said premises occupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time when loss occurred","type":"date","label":"Date and time of losses","options":[],"required":null,"pdf_field":""},{"help":"State who discovered the loss and when","type":"text","label":"When discovered and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain how entry or exit was affected during the loss","type":"text","label":"How was entry to / exit from the premises affected?","options":[],"required":null,"pdf_field":""},{"help":"Specify the affected area of the premises","type":"text","label":"Which portion of the premises was affected by the entry or exit?","options":[],"required":null,"pdf_field":""},{"help":"List stolen items and damaged property with details","type":"text","label":"Give brief detail of how exactly the loss occurred. (Specify the articles stolen and property damaged)","options":[],"required":null,"pdf_field":""},{"help":"Provide police complaint details and attach copy","type":"text","label":"Has a complaint been lodged with the police? If so, by whom and when and at which Police Station? (Attach a copy of the Police complaint.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were the premises occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide last occupancy date and time if premises were unoccupied","type":"date","label":"If not, on what date and at what hour were they last occupied?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any suspected persons","type":"text","label":"Is anybody suspected of theft? If so, state full details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Ownership and Insurance Details","fields":[{"help":"","type":"yes-no","label":"Is the Insured the sole owner of (a) The property lost or damaged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Insured responsible for repairs to the premises?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide total value of all property at loss time","type":"amount","label":"State the total value of property upon the premises at the time of loss.","options":[],"required":null,"pdf_field":""},{"help":"Provide insured amount and insurer names","type":"text","label":"State the amount of the insurance upon such property and name(s) of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance policies covering this loss","type":"text","label":"Is there any other Insurance against the present loss under any other policy? If so, give full particulars","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional relevant information","type":"text","label":"Any other 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 PEPs*? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answer to previous question 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":"Declarations and Signature","fields":[{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","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":"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":"Enter name exactly as in bank records","type":"text","label":"Payee Name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Payee Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account:","options":["Savings","Current","Others (specify)"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"Address of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code No. of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code if available","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee :","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Burglary Insurance claims","attachments":["Copy of the Police complaint"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having interest in the property are disclosed as per the proposal form or policy endorsement.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form or documents does not constitute admission of 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":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/518-claim-form-for-burglary-insurance"}