Scribd Logo
Upload

Welcome to Scribd!

  • 27 views

    Icici Lambord

    Uploaded by

    kveramallu
    form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Icici Lambord

    Uploaded by

    kveramallu
    27 views2 pages
    form

    Original Title

    ICICI LAMBORD

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views2 pages

    Icici Lambord

    Uploaded by

    kveramallu
    form

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.

    com or call 1800 2666

    Enrollment Form No - ___________________

    Enrollment Form for Group Home Protect Policy

    GUIDELINES FOR COMPLETION OF THE FORM (To be filled by proposer)


    Please answer all the questions fully and correctly. Where any question does not apply, please mention clearly that
    the same is not applicable.
    Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not
    to suppress any material facts in response to the questions in the enrollment form. If you think any fact is material,
    please disclose it. The Policy shall become void at the option of Insurer, in the event of any untrue or incorrect
    statement, misrepresentation, non-description or non-disclosure in any material particular in the enrollment
    form/personal statement, declaration and connected documents or any material information having been withheld
    by the Proposer or any one acting on his behalf. Kindly contact the Company’s Offices or Agents for any doubts or
    clarifications on the enrollment form.
    Note: The liability of the company does not coming until this proposal has been accepted and premium is received
    by the company.
    Date: Place: Applicant's Signature :
    CUSTOMER INFORMATION - PART A
    The application form is to be filled in CAPITAL LETTERS by the applicant. Please answer all questions fully and correctly. Where any
    question does not apply, please mention clearly that the same is not applicable
    Loan Account No. (LAN):
    Gender: Male Female Status of the Applicant: Loan Applicant Co-applicant
    Occupation: Salaried Self-employed Funded Non Funded
    Name of the Insured (Loan Applicant / Co-applicant to be Insured): Mr. / Mrs. / Ms.
    Mobile No.: Email ID:
    Type: New Renewal Type of Loan to be insured: HOME LOAN / LAP Loan Tenure: years
    Loan Sanction Date: Loan Sanction Amount :
    PAN No.: Loan Disbursal Date:
    Loan Disbursal Amount : GST No. (If applicable):
    *Premium Amount : Cheque Amount :
    Cheque No.: Cheque Name:
    Cheque Date: Hypothecation:
    *The proposed insurance coverage is subject to realization of full premium amount by the company, subject to agreed bank clause.

    GROUP HOME PROTECT POLICY - PART B


    Property Type: Residential Table of Benefit
    Sum Insured
    Loan Tenure (in years): Sr. Risk Covered /Limit of
    Policy Tenure: No. Indemnity (`)
    Sum Insured:
    Carpet Area:
    Cost of Construction:

    Property Details
    Address of Risk Location:
    District:
    State: Pin code:
    Declaration
    I understand that this policy is Group Policy and ICICI Home information has been withheld by me/us or anyone acting on
    Finance Company Limited has taken the policy for their Home Loan my/our behalf to obtain any benefit under this policy.
    customers. This policy is applicable to the Dwelling not more than * A material fact will mean and include all important, essential and
    50 years old. relevant information pertaining to the questions raised above
    I/ We have read and understood the terms and conditions of the herein that is likely to influence the Company's acceptance or
    Policy and confirm to abide by the same. I/We hereby agree that assessment of the proposal.
    the insurance coverage under the Policy will commence only on I/We declare that the contents of this enrollment form and other
    realization of full premium. Receipt of enrollment form by the documents have been fully explained to me/us and I/We have fully
    Company shall not be construed as acceptance of proposal. understood the significance of the proposed contract
    Company in its sole discretion reserves the right to accept or reject I understand that the insurance coverage will commence not
    any proposal as per the under writhing guideline of the Company. earlier than the date of disbursal of loan as referred overleaf or after
    I/We, the undersigned hereby declare that the above statements the full premium is received by ICICI Lombard General Insurance
    and particulars are true, accurate and complete and I/We declare Co. Ltd whichever is later subject to underwriting approval by ICICI
    and agree that this declaration and the answers given above shall Lombard General Insurance Company Ltd. Receipt of enrollment
    be held to be promissory and shall be the basis of the contract form by ICICI Lombard General Insurance Company Ltd shall not be
    between me/us and the Insurer. construed as acceptance of my proposal. The company in its sole
    I/we authorize the Company and their agents to exchange, share or discretion reserves the right to accept or reject any proposal
    part with all the information relating to my/ our personal and financial without assigning any reason thereof.
    details with Government bodies / Regulatory Authorities/ Statutory I also confirm and declare that the persons whose details have
    bodies or under court orders as may be required and I/ we will not been mentioned in this proposal for coverage are the applicant(s)
    hold the Company and its agents liable for use of this information. of the loan whose details have been mentioned in the enrollment
    I/we agree that the Policy shall become void at the option of the form.
    Insurer, in the event of any untrue or incorrect statement, I confirm that I have voluntarily participated for this
    misrepresentation, non-description or non-disclosure in any
    material fact* in the enrollment form/personal statement, policy.
    declaration and connected documents, or any material l/We declare that the quality of construction of the building is
    satisfactory.

    Cancellation Clause
    We may at any time, cancel this Policy on grounds of mis-representation, fraud, non-disclosure of material facts, or Your non-
    cooperation, by giving 15 day notice in writing by Registered post/Acknowledgement Due post to You at Your last known address in
    which case We shall refund a pro-rata premium for the unexpired Policy Period. You may also cancel this Policy by giving 15 day notice in
    writing, to Us in which case also, We shall refund a pro-rata premium for the unexpired Policy Period.

    Main Exclusions
    Kutcha Construction is excluded under this policy. Any loss due to direct or indirect involvement of Insured, cash, money and
    monetary instruments excluded from covers in the policy.
    Intentional self-injury, or breach of law with criminal intent, war, nuclear war, radioactive substances, any loss arising from an act made
    in breach of law with or without criminal intent. Leakage/ Seepage due to uninsured perils are excluded under the policy.
    For detailed exclusions refer to policy wordings.
    Date: Place: Applicant's Signature :
    STATUTORY WARNING
    PROHIBITION OF REBATES
    (Under Section 41 of Insurance Law)
    (Amendment Act 2015)
    1) No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an
    insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission
    payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a Policy accept
    any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
    2) Any person making default in complying with the provisions of this section shall be liable for a penalty, which may extend to ten
    lakhs.
    I further agree and understand that all such refunds shall be made subject to the Terms and conditions of policy/ policies and refund of
    premium by ICICI Lombard to Shall absolve ICICI Lombard from any and all
    liabilities arising out of the said policy /policies

    Applicant's Signature :
    Enrollment Form for GHPP

    ICICI Lombard General Insurance Company Limited


    Mailing Address: Interface Building No.11, 401/402, 4th Floor, New Link Road Malad (W), Mumbai - 400 064. Registered Office Address: ICICI Lombard House, 414, Veer Savarkar
    Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025. Visit us at www.icicilombard.com • Mail us at [email protected]
    Toll Free No.: 1800 2666 • Chargable No.: +91 92236 22666. Insurance is the subject matter of solicitation. IRDA Reg. No. 115. Misc 118. CIN: L67200MH2000PLC129408.
    Group Home Protect Policy, IRDA Product Code: 4040, UIN No.: IRDAN115CP0003V02202021

    You might also like