{"id":524,"title":"Travel Assure-Group Overseas Travel Insurance Claim Form","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/travel-assure-claim-form-(2).pdf","sha256":"cc845437f7c3f1069a9d3383e9eaa6fae42cbbc005f407a856ef944351a75035","pages":8,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders or claimants to file a claim under the Travel Assure-Group Overseas Travel Insurance policy for various covered contingencies during overseas travel.","notes":["Claims form consists of Information Sheet and relevant annexure; print only relevant annexure","Use original ticket/boarding pass or passport copy to prove travel dates","Attach all relevant documents requested for claim processing","Deductible amount as per policy schedule must be borne by claimant","Claims under Accident & Medical Section require Doctor's Report as per format","All claim settlements are made through NEFT as per IRDA circular; provide bank details accurately","KYC documents required only if claim amount exceeds ₹100,000","Use block letters where applicable","Submission of documents does not imply admission of liability","For termination of NEFT facility, give 15 days prior written notice to ICICI Lombard at corporate address"],"title":"Travel Assure-Group Overseas Travel Insurance Claim Form","submit":{"to":"customersupport@icicilombard.com","how":"e-mail or upload via digital claims portal","address":""},"purpose":"claim","sections":[{"title":"Information Sheet - Insured Details","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Policy Start Date:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Policy End Date:","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"Full Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Sex:","options":["Male","Female","Others ______________"],"required":null,"pdf_field":""},{"help":"Full current residential address","type":"text","label":"Current Address:","options":[],"required":null,"pdf_field":""},{"help":"Address where you reside overseas","type":"text","label":"Address in Country of Residence:","options":[],"required":null,"pdf_field":""},{"help":"Phone number while abroad","type":"phone","label":"Phone No. Overseas:","options":[],"required":null,"pdf_field":""},{"help":"Phone number in India","type":"phone","label":"Phone No. India:","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No:","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Passport number","type":"text","label":"Passport No.:","options":[],"required":null,"pdf_field":""},{"help":"Claim reference number if already provided","type":"text","label":"Claims Ref No.:(As provided)","options":[],"required":null,"pdf_field":""},{"help":"Politically Exposed Persons status","type":"yes-no","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or a Family member/ Close relatives/Associates of PEPs?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain relationship and position if PEP is yes","type":"text","label":"If yes, explain nature of relationship and position held by PEP:","options":[],"required":false,"pdf_field":""},{"help":"Name of PEP or related person","type":"text","label":"Full Name:","options":[],"required":false,"pdf_field":""},{"help":"Relationship to policyholder","type":"text","label":"Relationship with the Policyholder:","options":[],"required":false,"pdf_field":""},{"help":"Office phone number of PEP or related person","type":"phone","label":"Phone No. (Off):","options":[],"required":false,"pdf_field":""},{"help":"Residence phone number of PEP or related person","type":"phone","label":"Phone No. (Res):","options":[],"required":false,"pdf_field":""},{"help":"Email of PEP or related person","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Specify your role (e.g. policyholder, nominee, claimant)","type":"text","label":"In what capacity are you making this claim?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Claim Details and Bank Information for EFT","fields":[{"help":"Name of the patient for whom claim is made","type":"text","label":"Patient's Name: (in respect of whom claim is made):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Card or UHID number if applicable","type":"text","label":"Card No./ UHID No.:","options":[],"required":null,"pdf_field":""},{"help":"Claim number if already assigned","type":"text","label":"Claim Number (if allotted):","options":[],"required":false,"pdf_field":""},{"help":"Contact number","type":"phone","label":"Mobile/ Contact No.:","options":[],"required":null,"pdf_field":""},{"help":"Attach one of these documents for identity verification","type":"choice","label":"Please provide ANY ONE of the below documents of proposer/ policy holder-","options":["Self-attested copy of a valid Identity proof of the Proposer/Policy holder","Cancelled cheque copy","Bank attested copy of Passbook with IFSC code"],"required":true,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Proposer/ policy holder name* (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Proposer/ policy holder Bank account no.:","options":[],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code as per cheque leaf","type":"text","label":"IFSC code no. of the bank:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"KYC Documents (Part D)","fields":[{"help":"","type":"text","label":"Patient's Name: (in respect of whom claim is made):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Card No./ UHID No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number (if allotted):","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile/ Contact No.:","options":[],"required":null,"pdf_field":""},{"help":"Attach two passport size photos","type":"photo","label":"Two passport size photos of Proposer (stick in the space provided below)","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid identity proof","type":"choice","label":"One photocopy of proof of identity of Proposer (any 1 in the below list)","options":["Passport","PAN card","Voter’s Identity card","Driving license","Letter issued by Unique Identification Authority of India containing details of name, address and Aadhar number","Job card issued by NREGA duly signed by an officer of the State Government","Letter from a recognized Public Authority (as defined under Section 2 (h) of the Right to Information Act, 2005) or Public Servant (as defined in Section 2(C) of the ‘The Prevention of Corruption Act, 1988’)"],"required":true,"pdf_field":""},{"help":"Attach one valid residence proof","type":"choice","label":"One photocopy of proof of residence of Proposer (any 1 in the below list)","options":["Electricity bill","Ration card","Letter from any recognized public authority","Current statement of bank account with details of permanent/present residence address (as downloaded)","Current passbook with details of permanent/present residence address (updated upto the previous month)","Valid lease agreement along with rent receipt, which is not more than three months old as a residence proof","Telephone bill pertaining to any kind of telephone connection like mobile, landline, wireless, etc. provided it is not older than six months from the date of insurance contract","Employer’s certificate as a proof of residence (Certificates of employers who have in place systematic procedures for recruitment along with maintenance of mandatory records of its employees are generally reliable)","Written confirmation from the banks where the prospect is a customer, regarding identification and proof of residence"],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Claimant's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or claimant"},{"title":"Declaration","fields":[{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm declaration","type":"signature","label":"Claimant's/ Insured's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Authorization by Insured/ On Behalf of the Insured","fields":[{"help":"Sign here","type":"signature","label":"SIGNED (Claimant or authorized person)","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship if signing on behalf","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Insured's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or authorized person"}],"deadlines":["Immediate intimation to the helpline is required; failure may result in claim being admitted for no more than 75%","No expenses beyond US$ 1000 shall be incurred without prior approval","Retain original documents even after digital submission as they may be called for later"],"applies_to":"Travel Assure-Group Overseas Travel Insurance claims","attachments":["Original ticket/ boarding pass or copy of the passport indicating the travel dates","Doctor's Report as per format for Accident & Medical Section claims","Original bills & receipts for indemnity claims","Relevant documents requested at the time of claim submission","Self-attested copy of a valid Identity proof of the Proposer/Policy holder or Cancelled cheque copy or Bank attested copy of Passbook with IFSC code","KYC documents if claim amount exceeds ₹100,000: two passport size photos, proof of identity, proof of residence"],"declarations":["The information given in this claim form is true, correct and complete","No similar claim has been made to any other insurance company except as disclosed","No material information relevant to the claim has been withheld","False or fraudulent statements will void the policy and claims","Receipt of this form does not constitute admission of liability by the company","Authorization is given to ISM and ICICI Lombard to obtain and share information for claim investigation","Consent is given to verify identity through Central KYC Registry or UIDAI or other modes","Authorization to release medical and claim information to ICICI Lombard and its representatives","Acknowledgement that fraudulent claims may lead to prosecution"],"dropped_labels":0},"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/524-travel-assure-group-overseas-travel-insurance-claim-form"}