{"id":538,"title":"CLAIM FORM FOR MACHINERY BREAKDOWN 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/downloads/51-claim-form-machinery-breakdown-insurance-policy--retail.pdf","sha256":"e83ad8537b585290b41946d44fa6eb952b79ce1b35cf1b02a0485b98cfc053da","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured policyholder to notify and claim for physical loss or damage under the Machinery Breakdown Insurance policy.","notes":["Use original bills and documents only","Attach all required documents as listed","Claim intimation can be done via toll-free number, email or website","In case of third-party property damage or bodily injury, file an FIR if applicable","Surveyor will be appointed within 24 hours of claim reporting","RTGS/NEFT payment terms and conditions apply as stated","Submission of documents or bank details does not imply admission of liability","Keep a claim reference number for future correspondence"],"title":"CLAIM FORM FOR MACHINERY BREAKDOWN INSURANCE POLICY","submit":{"to":"assigned Claims Service Manager (CSM) or Surveyor","how":"submit claim form and documents via toll-free number, email, website or as instructed by CSM","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy no.","options":[],"required":true,"pdf_field":""},{"help":"Enter the full name of the insured","type":"text","label":"i) Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the address where you want to receive correspondence","type":"text","label":"ii) Address for correspondence","options":[],"required":true,"pdf_field":""},{"help":"Enter a valid phone number","type":"phone","label":"iii) Contact Number","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss or Damage Details","fields":[{"help":"Provide the exact date and time of the loss or damage","type":"date","label":"a) When did the loss or damage occur? (State date and time)","options":[],"required":true,"pdf_field":""},{"help":"Provide the date and time when the damage was first noticed","type":"date","label":"b) When was the damage discovered? (State date & time)","options":[],"required":true,"pdf_field":""},{"help":"Provide the location where the damage happened","type":"text","label":"c) State the site where the damage occurred.","options":[],"required":true,"pdf_field":""},{"help":"Provide the address where the damaged machinery can be inspected","type":"text","label":"Address where the loss can be inspected.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Damaged Machinery","fields":[{"help":"Specify the item damaged as per inventory","type":"text","label":"a) Item of the Inventory","options":[],"required":true,"pdf_field":""},{"help":"Enter the sum insured amount for the item","type":"amount","label":"b) Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Describe the type and capacity of the machinery","type":"text","label":"c) Type of machinery & its capacity","options":[],"required":true,"pdf_field":""},{"help":"Provide manufacturer details exactly as on the maker's plate","type":"text","label":"d) Manufacturers name and year of manufacture. (Full details as on maker's plate to be given)","options":[],"required":true,"pdf_field":""},{"help":"Provide the replacement cost including erection charges","type":"amount","label":"e) What is the cost of replacement of the machine by a new machine of the same size and capacity including its erection cost?","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Machinery Details","fields":[{"help":"State if guarantee period expired and the date","type":"text","label":"a) Has the period of guarantee expired? If so, when?","options":[],"required":true,"pdf_field":""},{"help":"Indicate if there is a maintenance agreement","type":"yes-no","label":"b) Do you have any maintenance agreement with the manufacturer/repairer?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide your estimate of the loss amount","type":"amount","label":"What is the estimated amount of loss or damage?","options":[],"required":true,"pdf_field":""},{"help":"Explain cause and circumstances of damage; attach sketch if possible","type":"text","label":"What was the cause of the damage and how did it occur? Is replacement required? (This question must be answered in detail and a sketch given wherever possible)","options":[],"required":true,"pdf_field":""},{"help":"Provide workshop details if known","type":"text","label":"Give the name and address of the workshop where repairs will be executed:","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Any additional information relevant to processing of claim.","options":[],"required":false,"pdf_field":""},{"help":"Provide details if other insurance covers this risk","type":"text","label":"Details of other/multiple insurance covering same risk","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Politically Exposed Person (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 close relative of a PEP*?","options":["Yes","No"],"required":true,"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":"Declarations and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Direct Fund Transfer/EFT Mandate","fields":[{"help":"Sign as account holder for EFT mandate","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["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":"Machinery Breakdown Insurance policy claims","attachments":["Original Blank Cancelled Cheque signed by the Payee","PAN Card copy of Payee","Photographs / Video of damaged property/item under claim","Document/s in support of admissibility of the claim (e.g. Service Engineer’s Report, Fire Brigade Report)","FIR / Final Police investigation report wherever applicable","Repair/replacement quotation, invoice and payment proofs for each item claimed","Documents substantiating the quantum & value of items under claim if not 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 initial survey"],"declarations":["The information provided in this claim form is true, correct and complete","All persons having interest in the property are disclosed as per proposal or policy endorsement","No similar claim has been made with any other insurance company except as disclosed","No material information relevant to claim processing has been withheld","False or fraudulent statements or concealment of information will void the policy and claims","Receipt of claim form or documents does not constitute admission of liability by the company","Consent is given to verify identity/address proof through Central KYC Registry, UIDAI or other modes"],"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/538-claim-form-for-machinery-breakdown-insurance-policy"}