ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
CLAIM FORM FOR ELECTRONIC EQUIPMENT POLICY
Notification of Physical Loss or Damage
(The issue of this form is not to be taken as an Admission of Liability)
Office Address: Cover Note / Policy No :
Period of Insurance :
Date of Accident :
Claim Number :
PLEASE ANSWER ALL QUESTIONS FULLY
1. DETAILS OF INSURED
i)
ii)
iii)
Name
Address for correspondence
Contact Number
(i)
(ii)
(iii)
2. When did the loss or damage occur?
(State date and time)
3. The address where the property (item)
covered is situated.
4.
a)
b)
c)
d)
e)
What was damaged?
Item of the Inventory
Sum Insured
The description of the equipment.
Manufacturer’s name and year of
manufacture. (Full details as on maker’s
plate to be given)
What is the cost of replacement of the
equipment by new equipment of the
same size and capacity
a)
b)
c)
d)
e)
LOGO
5a)
b)
Was the property brand new or second
hand?
What was the last occasion before
the damage when the equipment
was serviced or attended to for
maintenance or damage?
a)
b)
6. Is the damaged property totally
destroyed?
7. What has occurred and which parts of
the property are damaged to such an
extent the replacement is necessary?
8. Has the period of guarantee expired? If
so, when?
9. What is the estimated amount of loss or
damage?
10.
What was the cause of the damage and
how did it occur?
(This question must be answered in
detail and a sketch given wherever
possible)
11a)
b)
Has the property undergone any repairs
previously?
What was the nature of such repairs?
12. Give the name and address of the
repairer where repairs will be executed:
(Provisional repairs will be indemnified)
13. Any additional information relevant to
processing of claim.
I/We hereby agree, affirm and declare that:
a. The statements/information given/stated by me/us in this claim form are true, correct and complete.
b. The details of all persons having an interest in the property in respect of which the claim is being made are provided as per the proposal form or by way of an endorsement in the policy. Furthermore, save and except as provided or disclosed in this claim form, no claim made hereunder (or the same/similar claim) has been made or lodged with any other insurance company.
c. 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.
d. 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 thereunder in respect of any or all claims, past, present or future.
e. The receipt of this claim 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 the Insured