{"id":549,"title":"VEHICLE BUY BACK INSURANCE POLICY - CLAIM FORM","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/vehicle-buy-back-insurance-policy---claim-form.pdf","sha256":"4126168417124e6e0687ab52636d3be65b40e9e9168d91a51ba3ba9e2bccd4bd","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for insured persons to file a claim under the Vehicle Buy Back Insurance Policy after an incident involving their vehicle.","notes":["Issuance of this form is not an admission of liability.","Do not sell the vehicle without prior consent from insurer to prefer a claim.","Please fill this form in block letters and tick the boxes where appropriate.","Do not leave any field unanswered.","Please enclose a cancelled cheque leaf along with the claim form for NEFT mandate.","Attach legible copies of all required documents duly attested by insured."],"title":"VEHICLE BUY BACK INSURANCE POLICY - CLAIM FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"claim","sections":[{"title":"Vehicle and Policy Details","fields":[{"help":"Tick Yes or No","type":"choice","label":"Do you wish to provide any other information?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide additional information if Yes above","type":"text","label":"If yes, Details (If required you may please attach a separate sheet)","options":[],"required":false,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter claim number if already assigned","type":"text","label":"Claim No.","options":[],"required":false,"pdf_field":""},{"help":"Enter your vehicle registration number","type":"text","label":"Vehicle No.","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle chassis number","type":"text","label":"Chassis No.","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle engine number","type":"text","label":"Engine No.","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle make","type":"text","label":"Make","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle model","type":"text","label":"Model","options":[],"required":true,"pdf_field":""},{"help":"Enter mileage in kilometers or running hours","type":"number","label":"Mileage completed since new (in Kms) /Running Hours","options":[],"required":true,"pdf_field":""},{"help":"Enter vehicle registration date","type":"date","label":"Date of Registration","options":[],"required":true,"pdf_field":""},{"help":"Provide financier details if vehicle is hypothecated","type":"text","label":"Hypothecation details, if any","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Detail of Insured","fields":[{"help":"Enter full name of insured or claimant","type":"text","label":"Insured/Claimant Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter any contact number","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Enter office phone number if any","type":"phone","label":"Office No.","options":[],"required":false,"pdf_field":""},{"help":"Enter residence phone number if any","type":"phone","label":"Residence No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Incident Details","fields":[{"help":"Enter date of incident","type":"date","label":"Incident occurred on","options":[],"required":true,"pdf_field":""},{"help":"Enter location where incident occurred","type":"text","label":"Place of Incident","options":[],"required":true,"pdf_field":""},{"help":"Describe the incident in detail","type":"text","label":"Description of Incident","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated claim amount","type":"amount","label":"Estimated Cost of Claim","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Details of Routine Maintenance Servicing","fields":[{"help":"List maintenance or repairs done","type":"text","label":"Provide details of the routine maintenance servicing /repair that have been conducted","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Bank Details for Direct Fund Transfer / NEFT Mandate","fields":[{"help":"Enter bank name for fund transfer","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank code if applicable","type":"text","label":"Bank Name & Code","options":[],"required":false,"pdf_field":""},{"help":"Enter state of bank branch","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number for payment","type":"text","label":"Payee Account No.","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code if available","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter name of account holder","type":"text","label":"Name of Payee","options":[],"required":true,"pdf_field":""},{"help":"Enter UPI address if applicable","type":"text","label":"UPI Address","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration","fields":[{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":[],"applies_to":"Vehicle Buy Back Insurance claims","attachments":["Claim Form duly completed and signed","Mandate Form / NEFT of Insured account or Financier, if hypothecated","Claim Details along with resale value quotes / valuation report obtained by the Insured, if any","Regular service and maintenance history records","Current reading of Speedometer/Odometer/Hour meter","Financier Statement, if hypothecated","NOC / No Dues Certificate from Financier, if hypothecated","Original Sale Documents / Final Transfer set","Copies of all vehicle documents along with Originals for Verification","Original keys / accessories as supplied by OEM","Any other documents or Information as may be required by the company","Cancelled cheque leaf for Direct Fund Transfer/NEFT Mandate Form"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having interest in the asset 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 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 through Central KYC Registry, UIDAI or other modes for KYC."],"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/549-vehicle-buy-back-insurance-policy-claim-form"}