CLAIM FORM FOR FIDELITY GUARANTEE INSURANCE
(The issuance 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) Name
ii) Address
iii) Contact Number
2. i) Name of the defaulting employee in full
ii) His present address
3. Amount of loss sustained
4. Date of discovery of the loss
5. Date(s) of loss
6. How exactly was the defalcation committed? If space is not
sufficient, please give full and detailed particulars on a
separate signed sheet. (Also please attach a certified
statement containing all entries in the Insured's books of
accounts relative to the defalcation in the order of their dates).
7. Please reply fully to the following questions regarding the
duties of the employee at the time of defalcation:-
In what capacity was he engaged and where?
Money:
i) How did the money reach his hands?
ii) What was the largest sum that he held in his hands at any
one time and for how long?
iii) Was he allowed to pay out any amounts on the Insured's
behalf?
iv) Who authorised these payments?
v) Was he required to give printed receipts from a book with
counterfoils? If so, how often were the counterfoils
examined and checked and by whom?
vi) Were moneys paid into Bank by the defaulting employee?
If so, how often were Bank Books examined and checked
and by whom?
vii)What balance, if any, was allowed to be kept in his hand?
viii)How often were the Cash Accounts balanced and how
was their accuracy checked? Please explain fully
ix) How often were accounts sent direct to Customers
independently of the employee?
Stock:
i) Did the employee have charge of stock? If so, in what way
did stock reach his hands?
ii) Was he allowed to issue stores or materials independently?
If not, who authorised these issues?
iii) How often was the position of stock handled by the
employee checked?
iv) When was the last check made?
8. How often Account Book/ Stock Books were audited and by
whom? When was the last audit done?
9. Has the Insured any moneys, estate, or effects of the
employee in his possession? If so, give particulars with
amounts.
10. Does the Insured hold any other security from the employee?
If so, state its nature and amount.
11. Is the defaulting employee a member of a joint family, or does
he hold any property furniture or other effects?
If so, give details.
12. Has the employee any near relatives? If so, give their names
and addresses, if known.
13. i) Has the Insured taken any action against the employee?
If so, state the nature of action taken.
ii) Has the Insured initiated Departmental Enquiry against the
Employee? If so, state the outcome of the same.
14. Has the loss been reported to the Police? If so, state at which
Police Station and what action was taken by Police.
15. Any other relevant information.
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 here under (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 Insured:
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
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
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)
012532CF/SC
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