{"id":536,"title":"FINANCIAL SERVICES /INSTITUTIONS PROFESSIONAL INDEMNITY 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/claim-form-fipi-retail.pdf","sha256":"466eea49f1cbd12f9d87d9955199e5671209884cf2855a38879eed418994e180","pages":10,"collected":"2026-10-20","instructions":{"about":"This form is for reporting and claiming under the Financial Services / Institutions Professional Indemnity Insurance policy. It is filled by the insured party who holds the policy and is making a claim or reporting an incident.","notes":["The issue of this form is not to be taken as an admission of liability.","Attach all relevant documents as specified.","In case of third-party property damage/bodily injury/fire, file an FIR if applicable.","Insured shall not enter into compromise/settlement without written permission of the Company.","Use separate sheets if space is insufficient for details.","Contact toll-free number 1800 2666 or email customersupport@icicilombard.com for claim intimation."],"title":"FINANCIAL SERVICES /INSTITUTIONS PROFESSIONAL INDEMNITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"Mailing Address: 601 / 602, 6th Floor, Interface Building No. 16, New Link Road Malad (W), Mumbai - 400 064.\nEmail: customersupport@icicilombard.com\nWebsite: https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/Profession of Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid phone number","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide claimant's contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Date when claim was made","type":"date","label":"Date of claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the claim amount","type":"amount","label":"Amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Specify claimant's capacity","type":"text","label":"Capacity in which the claimant is making the claim i.e. as client, third party, any other)","options":[],"required":null,"pdf_field":""},{"help":"Describe the allegation and attach claim notice","type":"text","label":"Allegation in the claim ( Please attach a copy of the claim notice )","options":[],"required":null,"pdf_field":""},{"help":"Provide details if anticipating a claim","type":"text","label":"In case you anticipate a claim, please specify","options":[],"required":false,"pdf_field":""},{"help":"Explain reason and nature of error or omission","type":"text","label":"The reason why you anticipate such a claim, Nature of error or omission if any on your part","options":[],"required":false,"pdf_field":""},{"help":"Specify source and expected time of claim","type":"text","label":"From whom and when you anticipate such a claim","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Details","fields":[{"help":"Describe the professional service provided","type":"text","label":"Mention the type of professional service provided to the Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Date when service was provided","type":"date","label":"When was the service provided to Claimant / prospective claimant","options":[],"required":null,"pdf_field":""},{"help":"Provide date and manner of first knowledge","type":"text","label":"When and how did you first come to know of the error/omission","options":[],"required":null,"pdf_field":""},{"help":"Provide location address if applicable","type":"text","label":"Address of the location/construction site where the error/negligence has occurred","options":[],"required":false,"pdf_field":""},{"help":"Describe the incident briefly","type":"text","label":"Brief description of the incident which can lead to claim","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance if applicable","type":"text","label":"Give particulars of any other insurance, if any in respect of the same risk.","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","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":"Provide details if answer 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"},{"title":"Claims Reporting Instructions and Process","fields":[{"help":"Contact toll-free no. 1800 2666, email customersupport@icicilombard.com or use website https://coclaims.icicilombard.com/claimstracker/CommercialClaims/ccplandingpage.aspx to register claim and submit documents","type":"text","label":"Claim Intimation","options":[],"required":null,"pdf_field":""},{"help":"File FIR if applicable for third-party property damage/bodily injury/fire","type":"text","label":"File an FIR","options":[],"required":null,"pdf_field":""},{"help":"Claims Manager will appoint licensed surveyor within 24 hours of claim reporting","type":"text","label":"Surveyor Appointment","options":[],"required":null,"pdf_field":""},{"help":"Repair/replacement details will be assessed and approved by Claims Manager or surveyor","type":"text","label":"Assessment Approval","options":[],"required":null,"pdf_field":""},{"help":"Amount assessed for damaged asset's salvage value","type":"text","label":"Salvage","options":[],"required":null,"pdf_field":""},{"help":"Assessment report within 15 days of claim form receipt; claim decision within 7 days of assessment","type":"text","label":"Turnaround Time (TAT)","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declarations and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claims Reporting Form - Alleged Claim Details","fields":[{"help":"Name of insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of insured","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of insured","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Email of insured","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Date and time of alleged error/omission","type":"date","label":"Alleged Date & Time","options":[],"required":null,"pdf_field":""},{"help":"Person alleged for error/omission","type":"text","label":"Error/Omission/negligence of","options":[],"required":null,"pdf_field":""},{"help":"Name of alleged person","type":"text","label":"Name of the person who has been alleged for Error/Omission","options":[],"required":null,"pdf_field":""},{"help":"Designation of alleged person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Qualification of alleged person","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Describe the event briefly","type":"text","label":"Brief description of the event","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claimant","fields":[{"help":"Provide claimant details; attach extra sheet if needed","type":"text","label":"Give name/es, address/es occupation/s of Claimant (Attach separate sheet, if space not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Describe injury or damage; attach extra sheet if needed","type":"text","label":"Details of Injury/death/damage/loss to the claimant (Attach separate sheet, if space not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Number of victims involved","type":"number","label":"Number of victims","options":[],"required":null,"pdf_field":""},{"help":"Specify claimant's capacity and attach complaint/notice","type":"text","label":"Mention the capacity under which the claim is being made by the claimant (Attach the written complaint/notice given by the claimant)","options":[],"required":null,"pdf_field":""},{"help":"Provide property damage details if applicable","type":"text","label":"Has the accident caused damage to property? If so, give name/s and address/es of the owner/s of the property and full description of the property and state the nature and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Specify compensation amount claimed","type":"amount","label":"Mention the amount of compensation claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Compromise Details","fields":[{"help":"State if liable and reasons","type":"text","label":"Do you agree that you are liable for the incident. Give reasons","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons and strategy for compromise/settlement","type":"text","label":"Reasons for compromise / settlement Please provide comprehensive detail of all reasons, game-plans/strategy for the same.","options":[],"required":null,"pdf_field":""},{"help":"Describe current negotiation status","type":"text","label":"What is the present status of compromise/ settlement negotiations?","options":[],"required":null,"pdf_field":""},{"help":"Specify proposed liability amount","type":"amount","label":"What is the quantum of liability, you are proposing to agree to?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"Select yes or no","type":"yes-no","label":"Has any case been filed in any court of law/tribunal against you, in relation to the incident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide copies of notices/summons if yes","type":"text","label":"Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":[],"required":false,"pdf_field":""},{"help":"Provide copies of court orders if yes","type":"text","label":"Has the court passed any interim or final order? If yes, please provide copies of the same","options":[],"required":false,"pdf_field":""},{"help":"Attach all court documents submitted","type":"attachment","label":"Also provide copies of all the documents that have been submitted to the Court either by you or the Claimants.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Legal Advice","fields":[{"help":"Describe proposed response","type":"text","label":"The Insured’s proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"Provide legal advisor details and opinion if applicable","type":"text","label":"Does the insured propose to/has already availed of, any legal advice. If Yes, details of the lawyer/law firm together with their opinion","options":[],"required":false,"pdf_field":""},{"help":"Describe proposed steps if no legal advice taken","type":"text","label":"If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":false,"pdf_field":""},{"help":"Estimate legal or defense costs","type":"amount","label":"Estimated Legal/Defence Cost/fees which will be incurred","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide any other supporting evidence","type":"text","label":"Any other evidence in support of claim.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other insurance if any","type":"text","label":"Give particulars of any other insurance, in respect of the same risk.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Signature","fields":[{"help":"Location of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Settlement Form for Professional Indemnity Policy","fields":[{"help":"Specify settlement amount and attach proof","type":"amount","label":"What is the quantum of the settlement that has been arrived at between you and the Claimants? Please provide proof of the following (agreement, understanding, court order, court award etc).","options":[],"required":null,"pdf_field":""},{"help":"Provide court awarded liability amount and copy","type":"amount","label":"If decided by a court, what is the quantum of liability imposed on you? Please provide copy of the court award.","options":[],"required":false,"pdf_field":""},{"help":"Provide total defense costs incurred","type":"amount","label":"What are the total defence costs that have been incurred by you, till date, if any?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Consent","fields":[{"help":"Location of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["The completion and return of this form to the Company should not be delayed if any of the particulars required cannot be immediately given; they may be forwarded to the Company afterwards as soon as possible.","Assessment sheet / Survey report will be furnished within 15 days of receipt of claim form and documents.","Claim will be decided within 7 days of receipt of the assessment sheet / survey report."],"applies_to":"Financial Services / Institutions Professional Indemnity Insurance claims","attachments":["Copy of the claim notice","Claim bill / Claim Form duly filled up","Photographs / Video of damaged property/item under claim","Documents in support of admissibility of the claim (court proceedings, communications, invoices, payment proofs, investigation reports, counsel opinion, engagement letter)","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for items to be repaired or reinstated","Documents substantiating the quantum & value of the items under claim not to be repaired or reinstated","Offer for retention of salvage, if any","KYC / NEFT Details as per AML guidelines","Invoice copy / Goods Receipt Note / Monetary Claim on carrier / Damage Certificate","Any other document specified by the surveyor post completion of initial survey","Written complaint/notice given by the claimant","Copies of court notices/summons if any","Copies of court orders if any","Copies of all documents submitted to the court by insured or claimants","Proof of settlement (agreement, understanding, court order, court award etc.)","Copy of court award if decided by court"],"declarations":["The statements/information given in this form are true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","If any false or fraudulent statement/information is made or material information is concealed, the policy shall be void and no claim rights will exist.","Receipt of this form or supporting documents does not constitute admission of the claim by the Company.","The insured consents to the Company verifying identity/address proof through Central KYC Registry, UIDAI or other modes for KYC purposes."],"dropped_labels":2},"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/536-financial-services-institutions-professional-indemnity-insurance"}