{"id":521,"title":"CLAIM FORM FOR ICICI Lombard IAR Policy Notification of Physical Loss or Damage","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_icici-lombard-iar-policy.pdf","sha256":"b753ff2b43e15ecb34ed09ecae6a9c8a1ab5d87e102bd13e0ea43aafb85a3fe1","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify ICICI Lombard General Insurance Company Limited of a physical loss or damage claim under the IAR Policy.","notes":["The issue of this form is not an admission of liability.","Please answer all questions fully.","Politically Exposed Persons (PEPs) are defined on the form.","Attach copies of other insurance policies if applicable."],"title":"CLAIM FORM FOR ICICI Lombard IAR Policy Notification of Physical Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Claim Details","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"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":"Enter a valid phone number","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"If applicable, provide details of mortgagees or other interested parties","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined on the form","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or a Family member/ close relative/ Associates of a PEP*? If yes, please give details (Nature of relationship and position held by PEP):","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Other Insurance","fields":[{"help":"If insured with other companies, provide insurer name","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide policy numbers of other insurance","type":"text","label":"Policy No. (s).","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policies","type":"amount","label":"Sum Insured Rs.","options":[],"required":null,"pdf_field":""},{"help":"Start date of other insurance policy","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Loss","fields":[{"help":"Provide exact time and date when loss occurred","type":"date","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of the loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the insured item affected by the loss","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"State the use or occupation of the premises when loss happened","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if fire brigade was informed; if no, explain why","type":"yes-no","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Indicate if police was informed; if no, explain why","type":"yes-no","label":"Has the Fire / Loss been reported to Police? (If not, give reasons)","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Loss Inspection and Extent","fields":[{"help":"Provide location address for inspection of loss","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""},{"help":"Describe the extent of the loss in detail","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Information","fields":[{"help":"Provide any other relevant details to support the claim","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""},{"help":"Repeat of PEP declaration for confirmation","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member / Close relatives / Associates close relative of a PEP*? If yes, please give details (Nature of relationship and position held by PEP):","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form to confirm declaration","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"ICICI Lombard IAR Policy physical loss or damage claims","attachments":["Copies of other insurance policies if insurance is effected with other companies"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or concealed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this claim form does not constitute admission of liability by the company.","Consent is given to verify identity and address through Central KYC Registry, UIDAI or other modes.","Premiums have been and will be paid from legally acquired sources of income."],"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/521-claim-form-for-icici-lombard-iar-policy-notification-of-physical-loss-or-damage"}