MOTOR THEFT CLAIM FORM

(Investor's option to receive payments through EFT mechanism)

Information about Insured:
Policy /Covernote no. _______________________________________Claim no. __________________________
Name: ___________________________________________________________________________________
Correspondence Add: ________________________________________________________________________
_________________________________________________________________________________________
District: _____________________________________________________________ Pin: __________________
Resi Phone: __________________________________________ Mobile: _______________________________

Profession of the Insured: ________________________________________________________________________

Number of Vehicles owned by the Insured: Two wheelers ____________, Pvt Cars _____________, Others__________
Name of previous Insurer (If any): __________________________________________________________________
Previous period of Insurance: Policy start date: |__|__|/|__|__|/|__|__|__|__|
D D M M Y Y Y Y

Policy end date: |__|__|/|__|__|/|__|__|__|__|

D D M M Y Y Y Y

Number of motor claims in past 2 years: _____________________________________________________________

Information about Insured vehicle:

Registration no: ____________________________________

Make _____________________________Model: __________________________Variant: __________________
Engine no: _________________________________________________________________________________
Chassis no: ________________________________________________________________________________
Hypothecation With: _________________________________________________________________________
Anti Theft Devices in the Vehicle, ________________________________________________________________
Permit Details: ______________________________________________________________________________
Valid From:|__|__|/|__|__|/|__|__|__|__|to
D D M M Y Y Y Y |__|__|/|__|__|/|__|__|__|__|
D D M M Y Y Y Y

Fitness Certificate valid from : |__|__|/|__|__|/|__|__|__|__|

D D M M Y Y Y Y D D M M Y Y Y Y
to |__|__|/|__|__|/|__|__|__|__|

Details of Incident:

Date of theft: ________________________ Time of Theft ___________:_____________am/pm

Place of theft: _______________________________________________________________________________
Circumstances of theft : _______________________________________________________________________
__________________________________________________________________________________________
Has the theft been reported to the police: __________________________________________________________
when: ____________________________________________________________________________________
If not Reasons: ______________________________________________________________________________
Name of Police Station: _________________________________
FIR number / GDR Number: ______________________________
 Witness Details Driver Details
Name of Witness 1 : ___________________________ Name of Driver: _______________________________
Add: _______________________________________ Add : _______________________________________
___________________________________________ ____________________________________________
___________________________________________ ____________________________________________
Contact no: __________________________________ Contact no: __________________________________
Name of Witness 2: ____________________________ Driving Lic no: ________________________________
Add: _______________________________________ Lic valid from: _ _ / _ _ / _ _ _ _ to _ _ / _ _ / _ _ _ _
___________________________________________ Issuing RTO: _________________________________
___________________________________________ Type of Lic: Permanent / Temporary
Contact no: __________________________________
Who parked the vehicle? ________________________
By whom was the theft Noticed? __________________

Is the Insured sole owner of the Vehicle? Yes / No, If "No" specify details ____________________________________
___________________________________________________________________________________________
Person who has interest in Insured vehicle: __________________________________________________________
Nature of Interest: _____________________________________________________________________________
Keys of IV lying with: ___________________________________________________________________________
Contact no: __________________________________________________________________________________

DOCUMENTS REQUIRED:
1) Claim for duly Signed* 2) FIR Copy & FR/Court certified untrace report 3) Original Policy copy 4) RTO Intimation*
5) RTO transfer forms* 6) Purchase Invoice 7) Indemnity Bond* 8) Original RC 9) Keys 10) Statement
11) Fitness Certificate & Permit# 12) Claim discharge Voucher [Format Attached]
* Stamp required in case on non-individual. # Incase of commercial Vehicles.
Note: Additional documents required by us if any, will be intimated to you as & when required.
I/We hereby agree, affirm & declare that:
a. The statements/information given by me/us in this claim form are true, correct & complete.
b. Furthermore, save & except as provided or disclosed in this claim form, no claim made here under (for the same/similar claim)
has made or lodged with any insurance company.
c. No material information, which is relevant to the processing of the claim, which in any matter 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 mal information, I the policy shall be void & 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.
e. I/We have received a list of documents with this claim form & have under stood all the requirements to be fulfilled for
administration of this claim & the Company shall not be held responsible for any delay in settlement of claim due to non
fulfillment of requirements including the documents as mentioned above.

Place : ____________________________________ _______________________________________

Date : _________________ Signature/Thumb Impression of the Insured
 DISCHARGE VOUCHER
In consideration of ICICI Lombard General Insurance Co. Ltd. (the company) having agreed to pay an amount of
`____________________ (Rupees __________________________________in words) towards Claim
No._______________ preferred under Policy No. ____________ for the loss sustained by me/ us towards the
vehicle bearing No. _____________,
I/ We ________________________________________________ (name to be written) S/O __________________,
aged_______, R/O________________ (address to be mentioned) do hereby discharge ICICI Lombard General Insurance
Co. Ltd against any liability arising out in furtherance of this claim.
The claim assessment was done in consultation with me/ us.
The company after assessing the loss sustained has issued the Cheque in No. _____________ dated _________ in my/our
favour and the same was duly received by me/us. I/ we have accepted the payment towards full and final satisfaction of my
claim.
Place
Date Signature

Stamp (Rs. 1 revenue stamp)

Particulars to the insured to be mentioned

NEFT DISCHARGE VOUCHER

In consideration of ICICI Lombard General Insurance Co. Ltd. (the company) having agreed to pay an amount of Rs………
(Rupees……….. in words) towards Claim No ________________ preferred under Policy No ________________ for the
loss sustained by me/ us towards the vehicle bearing no ________________ ,
I/ We ________________________________________________(name to be written) S/O __________________,
aged _______, R/O ________________ (Address to be mentioned) do hereby discharge ICICI Lombard General Insurance
Co. Ltd against any liability arising out in furtherance of this claim.
The claim assessment has been done in consultation with me/ us.
I agree to receive the claim amount through NEFT in my account no ______________ as details provided by me on
assessment of the loss, sustained by the company.
Transfer of funds by the bank through NEFT shall construe as received by me and as acceptance of full and final payment
towards satisfaction of my claim and shall discharge the Company against all liability arising out in furtherance of claim.
I hereby enclose the below mentioned documents required for NEFT transaction:
• A blank cancelled cheque for verification of the particulars
• Photo ID Proof
• 1 Colour Photograph
• Residential Proof

Place
Date Signature

Stamp (Rs. 1 revenue stamp)

Particulars to the insured to be mentioned
 NEFT/EFT MANDATE FORM

1. Investor / Customer's name:

2. Particulars of Investor /Customer Bank Account:
A. Name of the Bank:
B. Name and Address of the Branch:

C. 9 - Digit code number of the bank and branch appearing on the MICR cheque issued by the bank. (I.e the MICR code Number)
D. Account number (as appearing on the cheque book)
E. IFSC Code number of the bank
F. Type of account:
Saving account Current account Cash credit account Loan account
G. E mail address - ( for receiving intimation via email for transfer of funds.)
H. Full address of the insured

I. Phone No of the insured

J. Name of the contact person for insured

Terms and Conditions for Payments through RTGS I 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 Condition 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.
(Please attach a blank cancelled cheque or photocopy of a cheque for verification of the particulars provided in this regard)
(In lieu of bank certificate to be obtained as under, please attach a blank cancelled cheque or a photocopy of a cheque or front page of your savings bank passbook issued by your bank for the verification of the above
particulars)
013065CF/SC Motor Third Party Claim Form

Date Signature of the Account Holder (Insured)

Regd. Office: ICICI Bank Towers, Bandra Kurla Complex, Bandra (East), Mumbai - 400 051
Corp. Office: ICICI Lombard GIC Ltd, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai-400025.
Visit us at www.icicilombard.com Mail us at ihealthcare@icicilombard.com
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile)