ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
Regd. Office: ICICI Bank Towers, Bandra Kurla Complex, Bandra (East), Mumbai – 400 051
CLAIM FORM FOR INLAND TRANSIT INSURANCE
Notification of Loss / Damage
(The issue 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 No.
(iv) Policy No.
2. Mode of conveyance Rail/Road
3. Name & address of the transport
carrier
4. LR/ RR/ AWB Number and Date
5. (i) Date of arrival of goods at destination
(ii) Date when delivery from carriers
applied for
(iii) Date when delivery of goods taken
(iv) Reasons for delay in taking delivery, if
any
6. External conditions of the goods on
arrival
7(i) Date and place when loss/damage
was noticed
(ii)
Whether remarks of carrier obtained
(iii) Whether open delivery obtained from
carrier
(iv) Date when the claim lodged on the
carrier
(Enclose copies of correspondence
with the Acknowledgement due Card )
(v) Whether Non Delivery/Damage
Certificate obtained from carrier
(Enclose the copy of certificate)
9. Description and cause of loss
10.(i) Estimate of loss.
(ii) Probable salvage value, if any
(iii) CIF / Invoice value of goods
11. Any other 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