{"id":522,"title":"CLAIM APPLICATION FORM FOR EMPLOYEE’S COMPENSATION 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/employee-compensation-claim-form---retail.pdf","sha256":"2b74d150dfaba218ce6e5adda07da770d05397235b149465b6fbde1eab319fc9","pages":8,"collected":"2026-10-20","instructions":{"about":"This form is for notifying ICICI Lombard General Insurance Company about a claim under Employee’s Compensation Insurance. It is filled by the insured employer or policyholder.","notes":["Use the form to notify claims and seek permission before settlement","Do not delay submission even if some information is pending; forward later as soon as possible","File an FIR if applicable (third-party property damage, bodily injury, fire etc.)","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting","Submit all relevant documents to the assigned Claims Manager or Surveyor","Statement of Wages must be filled carefully as per instructions to avoid delays","Politically Exposed Persons (PEPs) must be declared with details","Original bills and documents may be required as per surveyor's instructions"],"title":"CLAIM APPLICATION FORM FOR EMPLOYEE’S COMPENSATION INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload via website or to Claims Manager/Surveyor","address":"601 / 602, 6th Floor, Interface Building No.16, New Link Road Malad (W), Mumbai - 400 064; Email: customersupport@icicilombard.com; Website: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx"},"purpose":"claim","sections":[{"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":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Injured Person","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Write age in years and select sex","type":"text","label":"Age and sex","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Residential Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of occupation","fields":[{"help":"","type":"text","label":"What is the occupation in which the injured person is employed?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person engaged in this occupation when the accident occurred?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if previous answer is No","type":"text","label":"If not state fully the nature of the work he was doing at the time of the accident?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of employment","fields":[{"help":"","type":"yes-no","label":"Is the injured person in your direct employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if previous answer is No","type":"text","label":"If not give name and address of Contractor?","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"When did the injured person enter your service?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Accident","fields":[{"help":"Date and time of accident","type":"date","label":"Date and time of accident.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of accident.","options":[],"required":null,"pdf_field":""},{"help":"Describe accident briefly","type":"text","label":"Give brief description of the accident?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the claimant at the time of accident in the course of employment. If yes, state details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the injured person under the influence of alcohol or other intoxicant at the time of the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide details","type":"yes-no","label":"Was he guilty of any misconduct or disobedience to orders / rules, due to which incident occurred? If so, please give full particulars.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you satisfied that the injured person has met with a bona-fide accident of employment?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Injury","fields":[{"help":"Describe injury briefly","type":"text","label":"Give a brief description of injury?","options":[],"required":null,"pdf_field":""},{"help":"Attach doctor’s certificate","type":"number","label":"What is the % of disability if any? Attach a certificate of doctor confirming disability?","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"What is the probable period of the disablement?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospital","fields":[{"help":"","type":"yes-no","label":"Has the injured person been removed to hospital or medically attended?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of admission in hospital","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of discharge from hospital.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Return to Work","fields":[{"help":"","type":"yes-no","label":"Whether injured person has returned to work?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of return and number of days absent","type":"date","label":"If yes, then the date of return and no. of days of absence?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies if Yes","type":"yes-no","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time of receipt","type":"date","label":"Date and time of receipt of notice/summons from the authorities","options":[],"required":null,"pdf_field":""},{"help":"Describe status and next hearing date","type":"text","label":"What is the present status of the proceedings? Also give the next date of hearing.","options":[],"required":null,"pdf_field":""},{"help":"Attach all relevant court documents","type":"attachment","label":"Provide copies of all the documents that have been submitted to the Court either by you or the employee/claimants, and copies of all the documents received with the notice from the court.","options":[],"required":null,"pdf_field":""},{"help":"Attach copies if Yes","type":"yes-no","label":"Has the court passed any interim or final order? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copy if Yes","type":"yes-no","label":"Has the subject matter of the alleged claim/complaint been earlier reported to the Company by an Incident Reporting Form? If yes, please provide date of Incident Reporting Form, and append copy thereof","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if previous answer is No","type":"text","label":"If no, kindly submit a duly completed Incident Reporting Form / or set out here the Insured’s views/comments on the alleged incident which has resulted in the alleged claim or compliant arising.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"The Insured’s proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the insured propose to/has already availed of, any legal advise.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if previous answer is Yes","type":"text","label":"If Yes, details of the lawyer/law firm together with their opinion.","options":[],"required":null,"pdf_field":""},{"help":"Fill if previous answer is No","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"","type":"text","label":"Details of claims if any preferred by the affected party / claimant for the same loss from another source.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Give name and address of witness if any?","options":[],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Person","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":"Fill only if previous answer is Yes","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Consent","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Statement of Wages","fields":[{"help":"Enter months for wage period","type":"table","label":"Month","options":[],"required":null,"pdf_field":""},{"help":"Enter wages for each month","type":"table","label":"Wages","options":[],"required":null,"pdf_field":""},{"help":"Enter bonus for each month","type":"table","label":"Bonus","options":[],"required":null,"pdf_field":""},{"help":"Enter value of free quarters and other allowances","type":"table","label":"Value of Free Quarters and Any Other Allowances and Rs","options":[],"required":null,"pdf_field":""},{"help":"Total wages including allowances","type":"amount","label":"Total including all Allowances","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(a) Were the above stated wages paid, or fallen due for payment, to the injured person?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide absence details if applicable","type":"text","label":"(b) Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days? If so, give the following particulars:- Absent for days from to","options":[],"required":null,"pdf_field":""},{"help":"Date of employer signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Employer to sign here","type":"signature","label":"Signature of the Employer","options":[],"required":true,"pdf_field":""}],"filled_by":"employer"}],"deadlines":["Submit claim form and documents without delay even if some particulars are not immediately available","Survey report to be furnished within 15 days of receipt of claim form and documents","Claim decision within 7 days of receipt of survey report"],"applies_to":"Employee’s Compensation Insurance claims","attachments":["Certificate of doctor confirming disability","Copies of court notices/summons if any","Copies of court orders if any","Incident Reporting Form if previously submitted or to be submitted","Documents submitted to court and received from court","Photographs / Video of damaged property/item under claim","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs","Documents substantiating quantum & value of items under claim","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 surveyor"],"declarations":["The insured warrants the truth of all statements and understands that false or fraudulent statements will forfeit the claim and void the policy","Consent is given to the Company to verify identity/address proof through Central KYC Registry or UIDAI or other modes for KYC","Receipt of this form does not constitute approval for settlement; permission must be granted by the Company before settlement"],"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/522-claim-application-form-for-employees-compensation-insurance"}