{"id":526,"title":"CLAIM FORM MACHINERY LOSS OF PROFIT 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/machinery-loss-of-profit-insurance---retail.pdf","sha256":"67b4465798cd62fefea2b168efce2c2ed40ea1735a63ecc507b7254fba972db3","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder to claim insurance for loss of profits due to machinery breakdown under the Machinery Loss of Profit Insurance policy.","notes":["Fill the form in BLOCK LETTERS.","Leave one box blank between two words while writing the address.","Use only the original claim form; photocopies will not be accepted.","Notify the Company without delay as soon as loss or damage is known.","If any information is not readily available, send the form without delay and provide missing details later."],"title":"CLAIM FORM MACHINERY LOSS OF PROFIT INSURANCE","submit":{"to":"Company's Office or Intermediary","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"Policy Holder Information","fields":[{"help":"","type":"text","label":"Claim No","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Select your title","type":"choice","label":"Title* (Pls. Tick)","options":["Ms.","Mrs.","Mr."],"required":true,"pdf_field":""},{"help":"Enter full name of the insured","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Primary email address","type":"email","label":"Email ID 1","options":[],"required":false,"pdf_field":""},{"help":"Secondary email address","type":"email","label":"Email ID 2","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder's name","type":"text","label":"Name of the Account Holder (as appearing in the Bank Account)","options":[],"required":null,"pdf_field":""},{"help":"Fax number if available","type":"phone","label":"Fax No.","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter city or village name","type":"text","label":"City/Village*","options":[],"required":true,"pdf_field":""},{"help":"Enter street name","type":"text","label":"Street Name*","options":[],"required":true,"pdf_field":""},{"help":"Enter block or flat number","type":"text","label":"Block/Flat No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter floor number if applicable","type":"text","label":"Floor No.","options":[],"required":false,"pdf_field":""},{"help":"Full correspondence address","type":"text","label":"Correspondence Address","options":[],"required":null,"pdf_field":""},{"help":"Name of your bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch location","type":"text","label":"Location","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter building name","type":"text","label":"Building Name*","options":[],"required":true,"pdf_field":""},{"help":"Enter locality","type":"text","label":"Locality","options":[],"required":false,"pdf_field":""},{"help":"Enter nearby landmark","type":"text","label":"Landmark*","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pincode","type":"number","label":"Pincode*","options":[],"required":true,"pdf_field":""},{"help":"Post office name","type":"text","label":"Post Office","options":[],"required":false,"pdf_field":""},{"help":"Enter landline number","type":"phone","label":"Landline*","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Type of bank account","type":"text","label":"Account Type","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Select yes if applicable","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":"Describe relationship and position","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Machinery Loss of Profit Claim Details","fields":[{"help":"Select yes or no","type":"yes-no","label":"Whether any alterations have been made in the nature of business/occupation of the premise post inception of the policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe alterations if any","type":"text","label":"If yes, provide the details","options":[],"required":false,"pdf_field":""},{"help":"Enter interruption period","type":"text","label":"Period for which the insured business was interrupted due to reported breakdown","options":[],"required":null,"pdf_field":""},{"help":"Enter turnover amount","type":"amount","label":"Annual Turnover in the Preceding Financial Year","options":[],"required":null,"pdf_field":""},{"help":"Enter estimated reduction amount","type":"amount","label":"Estimated reduction in Turnover/Output post Loss","options":[],"required":null,"pdf_field":""},{"help":"Enter estimated reduction amount","type":"amount","label":"Estimated reduction in Gross Profit post Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Details of Previous Losses, (if any)","options":[],"required":false,"pdf_field":""},{"help":"Additional claim information","type":"text","label":"Do you wish to provide any additional information with respect to the claim?","options":[],"required":false,"pdf_field":""},{"help":"List other insurances if any","type":"text","label":"Give details of the insurances covering the same incident, if any","options":[],"required":false,"pdf_field":""},{"help":"Enter standing charges amount","type":"amount","label":"Standing Charges","options":[],"required":null,"pdf_field":""},{"help":"Enter expenses amount","type":"amount","label":"Expenses Incurred for Loss Minimization","options":[],"required":null,"pdf_field":""},{"help":"Describe claim details or attach separate statement","type":"text","label":"Statement of Claim: (Kindly attach separate statement if space provided ls not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Describe nature and extent of loss","type":"text","label":"Nature and Extent of the Machinery Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide other insurer details","type":"text","label":"Please provide the details of Material Damage Policy if purchased from some other insurer:","options":[],"required":false,"pdf_field":""},{"help":"Attach confirmation letter","type":"text","label":"Please provide the confirmation in writing to that effect from that insurer:","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Whether the Material Damage claim for the reported incident is admitted by the Insurance Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter estimated loss amount","type":"amount","label":"Estimate of Loss due to Machinery Breakdown","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Whether the Material Damage Policy is with us?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe cause of breakdown","type":"text","label":"Cause of Machinery Breakdown","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time of incident","type":"date","label":"Date & Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Enter location where loss occurred","type":"text","label":"Location of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe how the loss occurred","type":"text","label":"Description of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Provide machinery details and serial number","type":"text","label":"Full Details of the Machinery which Broke down and its Sr. No as mentioned in Policy Annexure:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration","fields":[{"help":"Sign the form","type":"signature","label":"Signature of Proposer's","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Machinery Loss of Profit Insurance claims","attachments":["Separate statement if space provided is not sufficient for Statement of Claim","Confirmation in writing from other insurer if Material Damage Policy is purchased from another insurer"],"declarations":["The claimant warrants the truth of all statements made in the form to the best of their knowledge and belief.","If any false or fraudulent statement or concealment of material information is made, the claim will be forfeited and the policy null and void.","Consent is given to the Company to verify identity and address proofs through Central KYC Registry, UIDAI, or other modes for KYC purposes."],"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/526-claim-form-machinery-loss-of-profit-insurance"}