Generic Claim Intimation

Claim Intimation

Select Type of User

I Am A/An*:

Individual Employee Details:

Internal Employee Details:

External Employee Details:

Corporate Employee Details:

Channel Partner Employee Details:

Enter Employee Id *:

Enter Password *:

Employee Name *:

Enter Email Id *:

Enter Employee Id *:

Employee Name *:

Enter Email Id *:

Enter Corporate Name *:

Enter Mobile Number *:

Enter Employee Id *:

Employee Name *:

Enter Email Id *:

Enter Channel Partner Name *:

Enter Mobile Number *:

Enter Individual Name *:

Enter Email Id *:

Enter Mobile Number *:

Enter OTP Received: *:

Resend OTP

CLAIM INTIMATION FORM

Bare Minimum Details (BMD) for Claim Registration

   Policy no*:

   Select Any One:      None Card No. Loan Account No.

   Card No:                                Card Type:

   Card Type(Debit/Credit etc)*:                  Saving Account No:

   Loan Account No.            Name of Bank*:

   Date Of Loss*:

Date of accident/ date of loss of job/ Date of loss of card/ date of death/ date of travel/ date of fraud on card/ date of baggage loss/ date of diagnosis of critical illness etc

Name Of Insured*:

on whose name the policy is (corporate name/ bank name/ individual’s name)

Name of Injured*:

who has incurred the actual loss i.e who has died/ who has met with accident/ who has lost job/ card etc

DOB of Injured:

Nature Of Loss*:

Accidental death/ death due to which critical illness/ accidental hospitalisation/ baggage loss while travel from and to location/ job loss with reason etc

Name of Claimant*:

Name of the person who is claiming

   Hospital Name:               Claim Amount

   Hospital Complete Address:

   Accident Description:

Communication Details

   Address1*:                          Address2:

   Address3:

   State*:                                       City*:

   Pincode*:

   Telephone No.:

   Mobile No.1*:                    Mobile No.2:

   Email Id 1:                           Email Id 2:

   REMARKS (If Any):

   Kindly keep a note of following things:

   1. Kindly note down your web reference number (WRN) and Policy No. after clicking the Submit button.
   2. Kindly upload your supporting documents on "Document Upload" tab.
   3. You can track your claim after clicking on "Track Your Claim" tab.
   4. Physical set of documents needed to be sent on the following address:
          ICICI Lombard Health Care,
          ICICI Bank Tower, Plot No.12,
          Financial District, Nanakram Guda, Gachibowli,
          Hyderabad, Telangana,
          PIN No.- 500032.
   5. Once your claim is registered a Claim Reference Number will be shared to you with the claim form and
       the checklist of documents required on your given contact details.

Claims & Wellness Management

Online Claim Tracking

Claim Intimation

Document Upload

Track Your Claim

Claim Forms

Claim Intimation

Select Type of User

CLAIM INTIMATION FORM

Bare Minimum Details (BMD) for Claim Registration

Communication Details