{"id":541,"title":"CLAIM FORM FOR MARINE INLAND TRANSIT 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/5-claim-form-marine-transit-insurance-commercial.pdf","sha256":"5de65d3cc2bf692a339febaba0f0f23a85bb4536541bec975d9f23107f2bbeb2","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured to notify and claim for loss or damage under Marine Inland Transit Insurance policies.","notes":["Answer all questions fully.","Attach original or copies of all relevant documents as listed.","In case of third-party property damage or bodily injury, file an FIR as per policy terms.","Claims Manager will appoint a licensed surveyor within 24 hours of claim reporting.","Use the toll-free number or email to register the claim and receive a claim reference number.","The form issue is not an admission of liability.","The form is for the insured to fill and submit."],"title":"CLAIM FORM FOR MARINE INLAND TRANSIT INSURANCE","submit":{"to":"assigned Claims Service Manager (CSM) or Surveyor","how":"submit documents to the assigned CSM/Surveyor as instructed","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for Correspondence","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid phone number","type":"phone","label":"Contact No.","options":[],"required":true,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Transport Details","fields":[{"help":"Select the mode of transport used","type":"choice","label":"Mode of conveyance Rail/Road","options":["Rail","Road"],"required":true,"pdf_field":""},{"help":"Provide full name and address of the carrier","type":"text","label":"Name & address of the transport carrier","options":[],"required":true,"pdf_field":""},{"help":"Enter the Lorry Receipt, Railway Receipt or Air Way Bill number and date","type":"text","label":"LR/ RR/ AWB Number and Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Delivery and Loss Details","fields":[{"help":"Enter the date goods arrived at destination","type":"date","label":"Date of arrival of goods at destination","options":[],"required":true,"pdf_field":""},{"help":"Date when you requested delivery from carrier","type":"date","label":"Date when delivery from carriers applied for","options":[],"required":true,"pdf_field":""},{"help":"Date when goods were actually received","type":"date","label":"Date when delivery of goods taken","options":[],"required":true,"pdf_field":""},{"help":"Explain any delay in taking delivery","type":"text","label":"Reasons for delay in taking delivery, if any","options":[],"required":false,"pdf_field":""},{"help":"Describe the condition of goods when received","type":"text","label":"External conditions of the goods on arrival","options":[],"required":true,"pdf_field":""},{"help":"Specify date and location where loss or damage was first observed","type":"text","label":"Date and place when loss/damage was noticed","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Carrier Remarks and Claims","fields":[{"help":"Indicate if carrier's remarks were obtained","type":"yes-no","label":"Whether remarks of carrier obtained","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if open delivery was obtained","type":"yes-no","label":"Whether open delivery obtained from carrier:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Date claim was lodged with carrier; attach correspondence copies","type":"date","label":"Date when the claim lodged on the carrier:(Enclose copies of correspondence with the Acknowledgement due Card)","options":[],"required":true,"pdf_field":""},{"help":"Indicate if certificate was obtained; attach copy","type":"yes-no","label":"Whether Non Delivery/Damage Certificate obtained from carrier (Enclose the copy of certificate)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss Description and Values","fields":[{"help":"Describe the loss and its cause","type":"text","label":"Description and cause of loss","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated monetary loss","type":"amount","label":"Estimate of loss.","options":[],"required":true,"pdf_field":""},{"help":"Enter salvage value if applicable","type":"amount","label":"Probable salvage value, if any","options":[],"required":false,"pdf_field":""},{"help":"Enter cost, insurance and freight or invoice value","type":"amount","label":"CIF / Invoice value of goods","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"Provide any other relevant details","type":"text","label":"Any other information relevant to processing of claim.","options":[],"required":false,"pdf_field":""},{"help":"Mention other insurance policies covering this risk","type":"text","label":"Details of Other 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 of PEP*?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered 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":"Declaration 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"}],"deadlines":["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":"Marine Inland Transit Insurance","attachments":["copies of correspondence with the Acknowledgement due Card","copy of Non Delivery/Damage Certificate","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.","repair/ replacement quotation, invoice and payment proofs for each and every item as claimed (if repaired or reinstated)","documents substantiating the quantum & value of the items under claim (if not repaired or reinstated)","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 information given in this claim form is true, correct and complete.","All persons having interest in the property are disclosed as per the proposal or policy endorsement.","No relevant material information has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this 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 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/541-claim-form-for-marine-inland-transit-insurance"}