{"id":545,"title":"CLAIM FORM FOR Cellular Network Insurance Notification of Physical Loss or 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/claim-form_cnp-policy.pdf","sha256":"63033dd20087f790e6eed539ff065bbb671c5b75d4e670b3850da0f35cc5885a","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the insured person to notify and claim for physical loss or damage under the Cellular Network Insurance policy.","notes":["The issue of this form is not an admission of liability.","Please answer all questions fully.","Attach copies of other insurance policies if applicable."],"title":"CLAIM FORM FOR Cellular Network Insurance Notification of Physical Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Claim Details","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim Number","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number.","options":[],"required":null,"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":null,"pdf_field":""},{"help":"PEP means Politically Exposed Persons as defined in the form","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":null,"pdf_field":""},{"help":"Only 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":"claimant"},{"title":"Details of Other Insurance","fields":[{"help":"Attach copies of such policies if insurance is with other companies","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No. (s).","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured Rs.","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Period From","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Loss","fields":[{"help":"Provide exact time and date","type":"text","label":"Time & Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Cause of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the affected item","type":"text","label":"Item of Policy affected (give description)","options":[],"required":null,"pdf_field":""},{"help":"Describe how the premises was used","type":"text","label":"Occupation of the premises at the time of Loss","options":[],"required":null,"pdf_field":""},{"help":"Yes or No and reasons if No","type":"text","label":"Has the Fire / Loss been reported to Fire Brigade? (If not, give reasons)","options":[],"required":null,"pdf_field":""},{"help":"Yes or No and reasons if No","type":"text","label":"Has the Fire / Loss been reported to Police? (If not, give reasons)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Loss Inspection Address","fields":[{"help":"Provide full address","type":"text","label":"Address where the loss can be inspected.","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Extent of Loss","fields":[{"help":"Describe the extent of loss","type":"text","label":"Extent of Loss (as more particularly described in the statement overleaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Additional Information","fields":[{"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":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Cellular Network Insurance","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 or concealment of information will void the policy and claims.","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 proof through Central KYC Registry, UIDAI or other modes for KYC purposes.","Premiums have been and will be paid from legally acquired and declared 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/545-claim-form-for-cellular-network-insurance-notification-of-physical-loss-or-damag"}