ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED.
DETAILS OF THE POLICY
Policy No: ______________________________________________________
Period of Insurance: ______________________________________________________
DETAILS OF INSURED:
1. Name of the Insured : ______________________________________________________
2. Address of the Insured: ______________________________________________________
______________________________________________________
______________________________________________________
3. Date of Birth: ______________________________________________________
4. Whether Self Employed/ Salaried: ______________________________________________________
CLAIM FORM FOR SECURE MIND POLICY
GUIDELINES FOR COMPLETION OF THE FORM
1. Please answer all questions fully and correctly. Where any question does not apply, please mention clearly that the same is not applicable.
2. The completion and return of this form to the Company should n be delayed if any of the particulars required cannot be immediately given. They may be forwarded to the Company afterwards, as soon as possible.
3. The Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or on non-disclosure in any material particularly in the claim form / personal statement, declaration and connected documents, or any material information having been withheld by the insured or any one acting on his behalf.
4. Kindly contact the Company’s Offices or Agents for any doubts or clarifications on the claim form.
5. On receipt of the claim form, communication for claim documents would be sent depending upon the nature of insured event for which the claim has been lodged
NOTE
· The issue of this form is not to be construed as an Admission of Liability.
· Please attach the photocopy (Xerox) of the policy document
· Please send the claim form to:
Secure Mind Claims
ICICI Lombard GIC Ltd, TGV Mansions, 5th and 6th Floor, Plot No. 6-2-1012,
Above ICICI Bank, Khairatabad, Hyderabad - -500 004
LOAN DETAILS
5. Name of the Financier : ________________________________________________________________
6. Loan Account No: ____________________________________________________________________
7. Sanctioned / Disbursed loan amount as on policy inception date :__________________________
8. Outstanding Loan Principal Amount:_____________________________________________________
9. Original Tenure of the Loan : ___________________________________________________________
10. Type of Loan (Home/ Auto/ Personal/ Others) : ___________________________________________
11. EMI amount payable on the Loan :______________________________________________________
12. EMI due date :_________________________________________________________________________
13. Any overdue payment of EMI: __________________________________________________________
CLAIM DETAILS
14. Nature of Insured Event: (Please tick the relevant box)
(i) Unemployment on account of (please
describe):______________________________________
Name and address of the organization where last employed
___________________________________________________________________________
Designation: _______________________________________________________________
Nature of Job ______________________________________________________________
Date of Termination / Retrenchment / Separation: __________________
(ii) Death due to accident
Date of Accident ____________________
Brief Narration of the Cause of accident_______________________________________
Place of accident____________________________________________________________
(iii) Permanent Total Disability due to Accident
Date of Accident ____________________
Brief Narration of the Cause of accident _______________________________________
Place of accident ___________________________________________________________
(iv) Major Medical Illness or Procedure :
a) Date of Diagnosis of Major Medical Illness or undergoing of surgery __________________
b) Please select the type of Major Medical Illness suffered or surgery undergone from the list below
Information Cancer
Information End Stage Renal Failure
Information Major Organ Transplant
Information Stroke
Information Paralysis
Information Heart Valve Replacement Surgery
Information Multiple Sclerosis
Information Coronary Artery By Pass Graft Surgery
Information Heart Attack (Myocardial Infraction)
Name of the treating doctor: _______________________________________________________________
Contact details of the treating doctor: _______________________________________________________
__________________________________________________________________________________________
Declaration
I 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) 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 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 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 claim form / other supporting/related documents does not constitute or be deemed to constitute an agreement by the Company to pay the claim and the Company reserves the right to process or reject or call for further / additional information in respect of the claim.
(e) As per the policy terms and conditions, the Company reserves its right to have the Insured examined by any doctor at any hospital / diagnostic centre or clinic appointed by it for verification of diagnosis / illness / ailment / procedure or disablement
I / We hereby declare that the particulars made by the insured person/claimant in the claim form are true to the best of my / our knowledge and belief. I also authorize ICICI Lombard Gen Ins Co to seek any medical information, document / report from any Medical Practitioner / Hospital or any other body / organization who has at any time attended / treated the insured for whom the claim is being lodged.
Name of Claimant:
Address for correspondence:
Phone No:
Email Address: Signature of Claimant
Date: ___________ Place: _______________