{"id":550,"title":"Financial Shield Package Policy – Group 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/claim-form-financial-shield-package-27032026.pdf","sha256":"aa7250f996ce7d59818b81b8180827a084e1045413e4db612c191048f0f4af09","pages":9,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person or claimant to lodge a claim under the Financial Shield Package Group Policy issued by ICICI Lombard General Insurance Company Limited.","notes":["Attach a separate sheet if space is insufficient for details.","Use self-attested copies for identity and bank documents.","Nominee’s bank account details are required in case of a death claim.","Original bills and documents may be required as informed by the insurer.","Submission of claim form is not admission of liability.","Claims can be lodged via website, toll-free number, or branch visit."],"title":"Financial Shield Package Policy – Group CLAIM FORM","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload / in person / with the hospital (not explicitly specified)","address":"ICICI Lombard General Insurance Company Limited, ICICI Lombard House 414, Veer Savarkar Marg, Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025"},"purpose":"claim","sections":[{"title":"Part I: Customer related details","fields":[{"help":"Enter your policy number as printed on your policy document.","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder.","type":"text","label":"Name of the Policyholder","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured person.","type":"text","label":"Name of the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format.","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Select the appropriate gender.","type":"choice","label":"Gender: Male / Female / Other","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Enter mobile or residential phone number.","type":"phone","label":"Contact Details: Mob. / Res. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address.","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhaar number in XXXX/XXXX/XXXX format.","type":"text","label":"Aadhaar Card No. of Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN card number.","type":"text","label":"Pan Card","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Part I: Claimant Details","fields":[{"help":"Enter full name of the claimant.","type":"text","label":"Name of claimant","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to the insured person.","type":"text","label":"Relationship of claimant with Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address for communication.","type":"text","label":"Address for communication","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile or residential phone number.","type":"phone","label":"Contact Details: Mob. / Res. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address.","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhaar number in XXXX/XXXX/XXXX format.","type":"text","label":"Aadhaar Card No. of claimant","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN card number.","type":"text","label":"Pan Card","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies including insurer name, policy/product name, policy number, policy period, and sum insured.","type":"table","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer) - If yes please specify details","options":[],"required":null,"pdf_field":""}],"filled_by":"Claimant (if different from Insured Person)"},{"title":"Part I: Loan Details","fields":[{"help":"Select if the policy is assigned to a financial institution.","type":"choice","label":"Is the policy assigned: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the name of the financial institution if policy is assigned.","type":"text","label":"Name of the Financial Institution","options":[],"required":null,"pdf_field":""},{"help":"Enter the Loan Account Number (LAN).","type":"text","label":"LAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the EMI amount.","type":"amount","label":"EMI amount","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant if policy linked to loan"},{"title":"Part II: Claim Details","fields":[{"help":"Enter claim number if already registered.","type":"text","label":"Claim No. (If claim has already been registered with ICICI Lombard)","options":[],"required":false,"pdf_field":""},{"help":"Enter the date when the loss/event occurred.","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of the loss or event.","type":"text","label":"Description of Loss/Event","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured Person / claimant"},{"title":"Claim documents","fields":[{"help":"Attach duly filled claim form, AML documents (PAN card copy, residence proof, 2 passport sized color photos), cancelled cheque and NEFT mandate form.","type":"attachment","label":"Generic claim documents","options":[],"required":true,"pdf_field":""},{"help":"Attach EPFO portal screenshot showing PF not credited, confirmation from third party vendor, and any other documents as informed.","type":"attachment","label":"Section A: Loss of job","options":[],"required":null,"pdf_field":""},{"help":"Attach e-complaint letter from Cyber Crime Portal, communication with bank, and any other documents as informed.","type":"attachment","label":"Section B: Cyber frauds","options":[],"required":null,"pdf_field":""},{"help":"Attach photographs of damaged assets, video inspection, and any other documents as informed.","type":"attachment","label":"Section C: Home Protect","options":[],"required":null,"pdf_field":""},{"help":"Attach details of incident date, nature of business, reason for shutdown, occupancy, surveyor report if required, and any other documents as informed.","type":"attachment","label":"Section D: Business Shutdown","options":[],"required":null,"pdf_field":""},{"help":"For hospitalization: hospital discharge summary and other documents as informed. For accidental death: FIR, death certificate, and other documents as informed. For PTD: FIR, disability certificate, and other documents as informed.","type":"attachment","label":"Section E: Family emergency","options":[],"required":null,"pdf_field":""},{"help":"Attach trip cancellation confirmation from carrier, ticket and refund receipt, hotel bills and refund receipts, medical evidence if applicable, and other documents as informed.","type":"attachment","label":"Section F: Trip cancellation","options":[],"required":null,"pdf_field":""},{"help":"Attach surveyor report and any other documents as informed.","type":"attachment","label":"Section G: Event Cancellation","options":[],"required":null,"pdf_field":""},{"help":"Attach indoor case papers, MIC/FIR, diagnostic reports, and other documents as informed.","type":"attachment","label":"Section H: Broken Bones Benefit","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Part IV: NEFT Details","fields":[{"help":"Enter name exactly as per bank records.","type":"text","label":"Claimant / Insured Person’s name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number.","type":"text","label":"Claimant / Insured Person’s bank account no.","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name.","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name of the bank.","type":"text","label":"Branch name","options":[],"required":true,"pdf_field":""},{"help":"Enter full address of the bank branch.","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per cheque leaf.","type":"text","label":"IFSC code no. of the bank","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Insured Person"},{"title":"Claimant/Insured Person Declaration","fields":[{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form here.","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the person signing.","type":"text","label":"Name of the Insured Person/claimant/Nominee","options":[],"required":true,"pdf_field":""},{"help":"Specify relation to the insured person.","type":"text","label":"Relation with the Insured Person","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Insured Person / Nominee"}],"deadlines":[],"applies_to":"Claims under the Financial Shield Package Group Policy","attachments":["Duly filled claim form","AML Documents - Pan Card Copy, Residence Proof, and 2 passport sized colour photos of Insured Person/claimant","Cancelled Cheque and NEFT Mandate form duly filled","EPFO portal screenshot for loss of job claims","Confirmation from third party vendor for loss of job claims","E-Complaint letter from Cyber Crime Portal for cyber fraud claims","Communication with bank for cyber fraud claims","Photographs and video inspection for Home Protect claims","Surveyor report for Business Shutdown and Event Cancellation claims","Hospital discharge summary for Family emergency hospitalization claims","FIR and Death Certificate for accidental death claims","Disability Certificate for PTD claims","Trip cancellation confirmation, tickets, hotel bills, medical evidence for Trip cancellation claims","Indoor case papers, MIC/FIR, diagnostic reports for Broken Bones Benefit claims","Self-attested copy of valid identity proof or cancelled cheque or bank passbook copy for NEFT"],"declarations":["The claimant undertakes to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited after confirmation from ICICI Lombard's bankers.","The RTGS/NEFT facility may have risks of non-payment due to regulatory or other reasons beyond ICICI Lombard's control.","The claimant agrees to indemnify ICICI Lombard against any claims or losses arising from RTGS/NEFT transactions.","ICICI Lombard may subcontract agents to carry out RTGS/NEFT obligations.","The claimant may terminate RTGS/NEFT facility with 15 days prior written notice to ICICI Lombard.","Termination notice is effective only after confirmation from ICICI Lombard.","Any RTGS/NEFT charges levied by the claimant's bank shall be borne by the claimant.","ICICI Lombard may amend terms and conditions with prior notice where feasible.","Submission of documents or bank details does not imply admission of liability by ICICI Lombard.","Notices may be given by hand, email, website, or post to claimant's last known address.","Terms and conditions governed by laws of India with jurisdiction at Mumbai.","The claimant declares all information is true, complete and authorizes ICICI Lombard to collect relevant information.","False or fraudulent statements or non-disclosure will void the policy and claims.","Receipt of claim form or documents does not constitute acceptance of claim by ICICI Lombard.","Policy may be voided for untrue or incorrect statements or non-disclosure.","Consent is given to verify identity 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/550-financial-shield-package-policy-group-claim-form"}