CLAIM FORM FOR MACHINERY BREAKDOWN.

Notification of Physical Loss or Damage

(The issuance of this form is not to be taken as an Admission of Liability)

PLEASE ANSWER ALL QUESTIONS FULLY

1. DETAILS OF INSURED
i) Name
ii) Address for correspondence

iii) Contact Number

2. a) When did the loss or damage occur? (State date and time)

b) When was the damage discovered? (State date & time)

c) State the site where the damage occurred.

3. Address where the loss can be inspected.

4. What was damaged

a) Item of the Inventory
b) Sum Insured
c) Type of machinery & its capacity
d) Manufacturers name and year of manufacture. (Full details
as on maker's plate to be given)
e) What is the cost of replacement of the machine by a new
machine of the same size and capacity including its
erection cost?
5. a) Has the period of guarantee expired? If so, when?

b) Do you have any maintenance agreement with the

manufacturer/repairer?
6. What is the estimated amount of loss or damage?

7. What was the cause of the damage and how did it occur?
Is replacement required? (This question must be answered
in detail and a sketch given wherever possible)
 8. Give the name and address of the workshop where repairs
will be executed:

9. 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

Direct Fund Transfer/EFT Mandate Form

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 :

• 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
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

012535CF/SC

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 [email protected]
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile)