{"id":528,"title":"Consequential Loss (Fire) Insurance Policy","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---consequential-loss-(fire)-insurance---retail.pdf","sha256":"5ff031bf21764361b8b4cca5bf39661d70da91cebefa42d26fc28fc42fcb0cc1","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for notifying and claiming consequential loss due to fire under the insurance policy. It is filled by the insured claimant.","notes":["Answer all questions fully.","The issue of this form is not an admission of liability."],"title":"Consequential Loss (Fire) Insurance Policy","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter claim number if already assigned","type":"text","label":"Claim Number","options":[],"required":false,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Address where communications should be sent","type":"text","label":"Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the insured","type":"phone","label":"Contact Number.","options":[],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposed applicants a PEP* or Family member/ Close relatives/Associates of PEPs*?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Describe relationship and position if applicable","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Other Insurance","fields":[{"help":"Name of other insurer if any","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number(s) of other insurance","type":"text","label":"Policy No. (s).","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policies","type":"amount","label":"Sum Insured Rs.","options":[],"required":false,"pdf_field":""},{"help":"Start date of other insurance","type":"date","label":"Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Loss","fields":[{"help":"Specify when the loss occurred","type":"date","label":"Time & Date of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of the loss","type":"text","label":"Cause of Loss","options":[],"required":true,"pdf_field":""},{"help":"Describe the insured item affected","type":"text","label":"Item of Policy affected (give description)","options":[],"required":true,"pdf_field":""},{"help":"State the use of premises when loss happened","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":true,"pdf_field":""},{"help":"Yes or No and reasons if not reported","type":"text","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":[],"required":true,"pdf_field":""},{"help":"Yes or No and reasons if not reported","type":"text","label":"Has the Fire / Loss been reported to Police? (If not, give reasons)","options":[],"required":true,"pdf_field":""},{"help":"Location of the damaged property","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""},{"help":"Describe the extent of the loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":true,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Consequential Loss (Fire) Insurance Policy claims","attachments":["Copies of other insurance policies if insurance is effected with other companies"],"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 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 will void the policy and claims rights.","Receipt of this form does not mean acceptance of the claim; the company may require more information or reject the claim.","Consent is given to verify identity/address through Central KYC Registry or UIDAI or other modes for KYC purposes.","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/528-consequential-loss-fire-insurance-policy"}