{"id":525,"title":"CLAIM FORM BOILER & PRESSURE PLANT 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/boiler-and-pressure-plant-insurance---retail.pdf","sha256":"d346d5ec03402c9302ec15fb6a174b23e46a926f12f215009ba216a52f5701c6","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to report and claim for losses or damages related to boiler and pressure plant insurance.","notes":["The issue of this form is not to be taken as an Admission of Liability.","All major repairs must be done only with prior approval of the insurers.","Attach true copies of inspection certificates and any written communication from third parties.","Politically Exposed Persons (PEPs) are defined as individuals entrusted with prominent public functions.","Statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938 is included."],"title":"CLAIM FORM BOILER & PRESSURE PLANT INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"Details of Insured and Loss Notification","fields":[{"help":"Date when the claim was reported","type":"date","label":"Date Of Intimation","options":[],"required":null,"pdf_field":""},{"help":"Name of the person reporting the claim","type":"text","label":"Claim Reported By","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured person or entity","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Type of insurance policy held","type":"text","label":"Type of Policy","options":[],"required":null,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Time when the claim was reported (hours and minutes)","type":"text","label":"Time Of Intimation","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss or damage occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Designation of the person filling the form","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Email address of the insured or claimant","type":"email","label":"E Mail ID","options":[],"required":null,"pdf_field":""},{"help":"Personal contact details","type":"text","label":"Personal contact","options":[],"required":null,"pdf_field":""},{"help":"Policy period start date","type":"date","label":"Period From","options":[],"required":null,"pdf_field":""},{"help":"Indicate if policy copy is available at the site of loss","type":"choice","label":"Policy copy available at loss site","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the cause of the loss or damage","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Estimated monetary value of the loss","type":"amount","label":"Estimated Loss","options":[],"required":null,"pdf_field":""},{"help":"Location address where the loss can be inspected","type":"text","label":"Address where loss can be assessed","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under the policy","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Name of contact person for correspondence","type":"text","label":"i. Name","options":[],"required":null,"pdf_field":""},{"help":"Correspondence address","type":"text","label":"ii. Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Contact phone number for correspondence","type":"phone","label":"iii. Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Location details of the boilers insured","type":"text","label":"Location of Boilers","options":[],"required":null,"pdf_field":""},{"help":"Address for inspection of loss","type":"text","label":"Address where the loss can be inspected","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of the affected boiler","type":"text","label":"a. Full description of Boiler in which explosion/collapse has occurred","options":[],"required":null,"pdf_field":""},{"help":"Insured value of the boiler involved","type":"amount","label":"b. Insured value of the Boiler which exploded/collapsed","options":[],"required":null,"pdf_field":""},{"help":"Detailed cause of explosion or collapse","type":"text","label":"Cause of explosion/collapse (Please give full information)","options":[],"required":null,"pdf_field":""},{"help":"Details of damage to the boiler where incident occurred","type":"text","label":"Particulars of a. Damage to the Boiler in which explosion originated or collapse occurred","options":[],"required":null,"pdf_field":""},{"help":"Details of damage to surrounding insured property","type":"text","label":"a. Damage to surrounding property of the insured, if any. directly resulting from the explosion/collapse","options":[],"required":null,"pdf_field":""},{"help":"Attach true copies of latest inspection certificates","type":"attachment","label":"a. In the case of Steam Boilers / Economisers, Superheats please give particulars of the latest inspection certificates issued by the Government Inspection Department (True copies of certificates should be supplied)","options":[],"required":null,"pdf_field":""},{"help":"Confirm if boiler was operated within safety conditions","type":"yes-no","label":"b. Was the Boiler at the time of accident operated within the conditions of pressure temperature and other safety requirements specified by Boiler Inspector of pressure and or other competent Authority","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Estimate of loss or repair costs for boiler","type":"amount","label":"a. Please give an estimate of the loss or the possible repairs / replacements costs in respect of","options":[],"required":null,"pdf_field":""},{"help":"Estimate of loss or repair costs for surrounding property","type":"amount","label":"b. your own surrounding property (damaged)","options":[],"required":null,"pdf_field":""},{"help":"Describe damage to third party property","type":"text","label":"a. Nature and extent of damage to property if any, belonging to third parties","options":[],"required":null,"pdf_field":""},{"help":"Describe any personal injury to third parties","type":"text","label":"a. Nature and extent of personal injury, if any, to third parties","options":[],"required":null,"pdf_field":""},{"help":"Details of notification to authorities","type":"text","label":"Has the explosion/collapse been notified to the Government/ Statutory/Local Authorities? If so, to whom and when?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of approved repair contractors","type":"text","label":"In case of repairs to Boiler, please state whether competent and approved Repairs are available locally if so: give names and addresses of Repairs NOTE: All major repair entrusted to any Repair or Contractor must be done only with the prior approval of the Insurers.","options":[],"required":null,"pdf_field":""},{"help":"Details of any other insurance covering the damaged property","type":"text","label":"Are there any other insurance effected by you or any other person covering the property damaged or any part thereof? If so, please give details","options":[],"required":null,"pdf_field":""},{"help":"Names and addresses of owners of damaged property","type":"text","label":"b. Names and addresses of owners of property so damaged","options":[],"required":null,"pdf_field":""},{"help":"Details of injured persons","type":"text","label":"b. Names, addresses, and ages of injured persons","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any communication from third parties and attach written communication if any","type":"text","label":"Has any communication, verbal or written, been made to you by or on behalf of any injured person or owner of third party property involved in the damage? If so, please give particulars (Any written communication received must accompany this form)","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing the form","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured or proposer","type":"signature","label":"Proposer's Signature","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any applicant is a Politically Exposed Person or related","type":"choice","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":"Provide details if answer above 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"}],"deadlines":[],"applies_to":"Boiler and pressure plant insurance claims","attachments":["True copies of latest inspection certificates issued by the Government Inspection Department","Any written communication received from injured persons or owners of third party property"],"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 the proposal form or policy endorsement.","No material information relevant to the claim has been withheld or not disclosed.","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 the company to verify identity/address proof through Central KYC Registry or UIDAI or other modes."],"dropped_labels":4},"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/525-claim-form-boiler-and-pressure-plant-insurance"}