{"id":533,"title":"CLAIM FORM FOR ENERGY PACKAGE INSURANCE (Notification of Physical Loss/ Damage)","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/70-claim-form---energy-package-insurance---retail.pdf","sha256":"2180e1ad0079edf24aa38aed008694b60ecc89103360238e07143df7ba104353","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for physical loss or damage under the Energy Package Insurance policy.","notes":["Use the toll-free number 1800 2666 or email customersupport@icicilombard.com for claim intimation.","In case of third-party property damage or bodily injury, file an FIR if applicable as per policy terms.","A licensed surveyor will be appointed within 24 hours of reporting the claim.","Submit all relevant documents along with this claim form.","Salvage means the amount assessed which the damaged asset will fetch in the open market, where applicable."],"title":"CLAIM FORM FOR ENERGY PACKAGE INSURANCE (Notification of Physical Loss/ Damage)","submit":{"to":"assigned Claims Manager (CSM) / Surveyor","how":"submit documents to the assigned CSM/Surveyor as per claim process","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Location and Details","fields":[{"help":"Provide the exact port or location including latitude and longitude where the loss happened.","type":"text","label":"State The name of Port/ Location (Latitude/ Longitude) where the Loss Occurred.","options":[],"required":null,"pdf_field":""},{"help":"Provide the date and time when the loss occurred.","type":"date","label":"Date and time of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of the loss.","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Remedial Measures and Salvage","fields":[{"help":"Describe any actions taken to remedy the loss or damage.","type":"text","label":"Details of remedial measures taken.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if salvage services were used.","type":"yes-no","label":"Are any salvage services used.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if General Average has been declared.","type":"yes-no","label":"Whether General Average declared.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Damage to Other Ships/Property","fields":[{"help":"Provide details of any damage caused to other ships or property.","type":"text","label":"Details of damage to other Ships/Property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Vessel Status","fields":[{"help":"Indicate if the vessel has been declared Total Loss/Constructive Total Loss.","type":"yes-no","label":"Has the vessel been declared a TL/CTL","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if any notice of abandonment has been given.","type":"yes-no","label":"Has any notice of Abandonment been given?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance","fields":[{"help":"Provide details of any other insurance covering this loss.","type":"text","label":"Is there any other Insurance against the present loss under any other policy? If so, give full particulars.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide any other information relevant to the claim.","type":"text","label":"Any other relevant information","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"PEP Declaration","fields":[{"help":"Select Yes or No.","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 answered Yes above.","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Enter the place of signing.","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing in DD/MM/YYYY format.","type":"date","label":"Date : D  D /  M  M / Y  Y  Y  Y","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Energy Package Insurance claims related to physical loss or damage","attachments":["Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Invoice copy & packing list","Lorry Receipt/ Bill of Lading/ Bill of Entry/ Air way bill/ Goods receipt Note – as applicable","Monetary Claim or transporter","Damage Certificate","Document/s in support of admissibility of the claim, for instance, Service Engineer’s Report, Fire Brigade Report, etc.","For items which are to be repaired or reinstated, repair/ replacement quotation, invoice and payment proofs for each and every item as claimed.","For items which are under claim & not to be repaired or reinstated, documents substantiating the quantum & value of the items under claim","Offer for retention of salvage, if any","KYC / NEFT Details as per AML guidelines","Any other document which may be specified by the surveyor post completion of initial survey"],"declarations":["The statements/information given in this claim form are true, correct and complete.","The issue of this form is not to be taken as an Admission of Liability."],"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/533-claim-form-for-energy-package-insurance-notification-of-physical-loss-damage"}