Claim Form For Corporate Cover

CLAIM FORM FOR CORPORATE COVER
Notification of Loss or Damage
(The issuance of this Form is not to be taken as an Admission of Liability)
GENERAL INFORMATION
1. INSURED DETAILS
i) Name of the Insured
ii) Policy No.
iii) Policy Period From To
iv) Address
v) Contact Number
2. LOSS DETAILS
i) Date and Time of Loss
ii) Date and Time of Discovery
iii) Address of the premises where the loss occurred
iv) Cause of Loss
v) Brief description of incident.
vi) Estimated loss amount
vii)Other insurance on same loss. If yes details
viii)Any other information relevant to processing of claim
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Fire & Special Perils- Building
and Contents cover, please complete the following:
1. Whether the premises was occupied at the time of fire / loss? Y/N, If No, Date _____________Time ____________Location
Please provide the date from when it was vacant.
2. Has the fire / loss been reported to fire brigade and Police? Y/N, If No, FIR No.
give reasons
3. State whether the property damaged, is Hypothecated / Lease / Hire Hypothecation Party Name:
purchase, If yes give details? Period of such Hypothecation:
Value of such loan:
4. Description of property damaged with estimated value.
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the All Risk - Functional
Equipment or the All Risk - Non Functional Items cover, please complete the following:
1. Place & address where the loss took place.
2. Nature of loss/ damage.
3. Details of property damaged/lost
4. State the circumstances of the loss or damage
5. Estimated value of items lost or Damaged
6. Date and time of reporting the loss to Police Station.(Please furnish copy
of FIR)
7 Are you the sole owner of the property? If no, provide the details.
8 Any other information relevant to processing of claim
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Burglary cover, please
complete the following:
1. Were the premises occupied at the time of loss?.If not, on what date and at what hour were they last occupied?
2. Is anybody suspected of theft ? If so, state full details.
3. Is the Insured the sole owner of
(a) The property lost or damaged ?
(b) If no, the property belongs to whom ?
(c) Is the Insured responsible for repairs to the premises ?
4. Value and description of contents lost. (Attach separate sheet)
5. Any other information relevant to processing to claim
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Public Liability/ Employers
Liability / Personal Accident cover / Tenants Legal Liability, please complete the following:
1. Details of the Injured Person
i) Name
ii) Age and sex
iii) Residential Address
2. Details of occupation
i) What is the occupation in which the injured person is employed?
ii) Was the injured person engaged in this occupation when the accident
occurred? If not, state fully the nature of the work he was doing at the
time of the accident?
3. Details of employment
i) Is the injured person in your direct employment? If yes provide the
wages, bonus and other allowances payable per annum to the
employee
4. Details of Injury
i) Give a brief description of injury?
ii) What is the % of disability if any? Attach a Certificate of a Doctor
confirming disability?
iii) What is the probable period of the disablement?
5. Details of Hospital
i) Has the injured person been removed to Hospital or medically
attended? If yes, give name and address of hospital attending to
injured person?
ii) Date of admission in Hospital
iii) Date of discharge from Hospital.
6. Court Procedure
i) Has any case been filed in any Court of Law/tribunal against you,
in relation to the accident?
ii) Date and time of receipt of Notice/Summons from the Authorities.
Attach all documents received with the Notice from the Court.
iii) Does the Insured propose to/has already availed of, any legal advise.
If Yes, details of the lawyer/law firm together with their opinion
iv) Any other information relevant to processing of claim
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Mediclaim cover, please complete the following:
1. Name of the Insured:
i) Name of the Insured Employee
ii) Salary Roll No.
iii) Policy No.
2. Details of the Insured Person in respect of whom claim is made:
i) If family member, name & relationship to the Insured employee:
ii) Present completed age Occupation:
iii) Residential address
3. Nature of disease / illness contracted or injury suffered:
4. Date of injury sustained or disease / illness first detected
5. i) Name and address of the attending medical practitioner:
ii) Registration number of the Hospital / Nursing Home / Clinic
iii) Date of admission
iv) Date of discharge:
6. State whether Pre or Post Hospitalization expenses are incurred.
If yes, please give details of such expenses.
(To be filled in by the Employer/Insured)
Was the injured person in respect of whom claims being made absent from work? Yes/No
If so, please furnish the details of such absence
I / We hereby declare that the particulars made by the injured person in the claim from are true to the best of our knowledge and belief.
Place :
Date : Signature of the Insured
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Glass Breakage cover, please complete the following:
1. Total value of loss / damage (description to be enclosed in the separate sheet)
2. Whether the breakdown / damage is repairable / total loss ? Attach the estimate of repairs
3. Whether the premises was under construction/ occupied or vacant, if vacant period of vacancy
4. Describe the nature of glass
5. Any other information relevant to claim
If the loss or damage in respect of which this claim is being preferred was caused by an insured peril under the Cash in Safe or Cash in
Transit or Fidelity or Cheque Forgery cover, please complete the following:
Cash in Safe/Transit
1. Did the loss occur when the money was kept in safe or whilst in transit?
2. If in Safe
i) Name of the location(s) and details
ii) In whose custody were the Safe keys?
iii) Total amount of money in safe at time of loss
3. If in Transit:
i) Date & Time when loss was discovered.
ii) Places between which money was in transit
iii) How & where did the loss occur?
What was the amount carried?
Cheque Forgery
1. Mention the bank from on which the cheque was drawn
2. Amount of money forged
3. Is anybody suspected of fraud
4. Brief description of forgery
5. Any other information relevant to processing of claim
PROFESSIONAL INDEMNITY
INCIDENT REPORTING FORM
DETAILS OF INSURED
Name
Policy No.
Occupation of the Insured
Address
Contact No
Email id
A) Would you like to opt for Electronic Fund Transfer as mode of payment ? A) Yes B) No
B) If yes, kindly provide the below mentioned details :
• Payee Name (as per bank records):
• Payee Account No.:
• Type of Account: Savings Current Others (specify):
• Name of the Bank :
• Branch Name :
• Address of the Bank :
Direct Fund Transfer/EFT Mandate Form
• IFSC Code No. of the Bank:
• MICR Code No. of the Bank:
• Permanent Account Number (PAN) of Payee :
1) Please attach an Original Blank Cancelled Cheque signed by the Payee. Mandatory
2) Please attach a PAN Card copy of Payee Mandatory
DETAILS OF CLAIMANT
When was alleged error /omission actually committed
Name of the Claimant
Capacity of the Claimant
Address
Contact No.
When did you first come to know of the error/omission.
Brief description of the incident
Give particulars of any other insurance, if any in respect of the same risk.
I/We hereby agree, affirm and declare that:
a) The statements/information given/stated by me/us in this incident reporting form are true, correct and complete.
b) No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed.
c) If I/we have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose material information, the Policy shall be void and that I/We shall not be entitled to all/any rights to recover there under in respect of any or all claims, past, present or future.
d) The receipt of this incident reporting form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the Company of the claim and the Company reserves the right to process or reject or require further/additional information in respect of the claim.
Place:
Date: Signature of Insured:
Terms and Conditions for Payments through RTGS / NEFT
1. The details provided by the Customers in the Mandate Form shall be considered as final and ICICI Lombard General Insurance Company Ltd. shall not be responsible for cross verification of any of the details provided therein.
2. The RTGS / NEFT facility shall be effective for the respective Customer(s) within 15 days of the receipt of the Mandate Form by ICICI Lombard General Insurance Company Ltd. and/ or within such period as may be reasonably required by ICICI Lombard General Insurance Company Ltd. to activate the RTGS/ NEFT facility.
3. The Customer agrees that under the RTGS/ NEFT facility, there may be a risk of non-payment in the Account of Customer on the day of the credit of Payments due to change in the applicable regulations pertaining to RTGS/ NEFT facility or due to any other reasons without any fault/inaction/failure on part of ICICI Lombard General Insurance Company or any factor beyond the control of ICICI Lombard General Insurance Company Limited.
4. The Customer agrees to indemnify, without delay or demur, ICICI Lombard General Insurance Company Ltd. and its agents and keep ICICI Lombard General Insurance Company Ltd. and its agent indemnified harmless at all times from and against any and all claims, damages, losses, costs, and expenses (including attorney's fees) which ICICI Lombard General Insurance Company Ltd. may suffer or incur, directly or indirectly, arising from or in connection with, amongst other things, either of the aforesaid reasons stated in above clauses.
5. ICICI Lombard General Insurance Company Ltd. may sub-contract and employ agents to carry out any of its obligations under the RTGS/ NEFT facility. The Customer may discontinue or terminate the use of RTGS / NEFT facility by giving a minimum of 15 days prior written notice to ICICI Lombard General Insurance Company Ltd. The date of notice for ICICI Lombard will be the date of receipt of such notice by ICICI Lombard. The notice of such termination should be given to ICICI Lombard only at its corporate address and be addressed at ICICI Lombard GIC Ltd, ICICI Lombard House (Old Tata Press Building), 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - 400025
6. A confirmation of the receipt of termination notice given by the Customer will be acknowledged through a confirmation letter by ICICI Lombard General Insurance Company Ltd. In no case can the Customer construe his termination notice as effective unless a confirmation has been provided by ICICI Lombard to the Customer stating the date of receipt of such communication by the Customer.
7. The Customer agrees that transaction(s) through RTGS/ NEFT facility may attract inward RTGS/ NEFT charges, which if levied by the Customer's bank, shall be borne by the Customer
8. ICICI Lombard has the absolute discretion to amend or supplement any Terms and Conditions stated herein at any time and will endeavor to give
prior notice of Ten days for such changes wherever feasible for the terms and conditions to be applicable. By using the new services, or at the completion of such period, whichever is earlier, the Customer shall be deemed to have accepted the changed terms and conditions.
9. Submission of documents or bank details or any other information does not in any way, shape or form, imply or express or suggest admission of liability by the company.
10. Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or on ICICI Lombard General Insurance Company Ltd. website www.icicilombard.com or by sending them by post to the last address of the Customer.
11. These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of these Terms and Conditions shall be initiated in the courts or tribunals at Mumbai in India.
12. I / We further undertake to refund any excess amount whether demanded by ICICI Lombard General Insurance Company Ltd. or not, which has been credited in excess to my account at any time due to any reason within 7 days of such receipt of such communication from ICICI Lombard of such excess credit or such information of excess credit coming to the knowledge of the Customer through any other source.
13. I/ We agree that my/our claim payment will be credited from the date ICICI Lombard General Insurance Company Ltd. gets confirmation from its bankers, This facility will continue unless it is revoked by any party and any issuance of relevant credit instruction from ICICI Lombard General Insurance Company Ltd. to its bankers will be valid till such instruction is complete irrespective of the fact that the notice period has expired provided such a credit request has been made by ICICI Lombard General Insurance Company Ltd. before the expiry of the notice period of the Customer.
Signature of the Account Holder
Regd. Office: ICICI Bank Towers, Bandra Kurla Complex, Bandra (East), Mumbai - 400 051
Mailing Address: Property Claims Team, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025.
Visit us at www.icicilombard.com Mail us at customersupport [at] icicilombard [dot] com
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile)
012528CF/SC