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com or call 1800 2666

UIN:IRDAN115RP0005V01202021

ICICI BHARAT GRIHA RAKSHA POLICY

Important

PROPOSAL FORM

1. This proposal is for covering Home Building and/or Home Contents against Fire and Allied Perils.
2. Read the Prospectus/Key Features Document/Policy Wordings before filling up this proposal form to understand the
meaning of the terms used herein better.
3. The property proposed for insurance is not covered until the proposal is accepted and premium paid.

Policy Issuing Office Address & Code: ICICI Lombard General Insurance Co. Ltd. Ground Floor - Interface 11, Sixth Floor, Interface
16, Office No. 601 & 602, New Linking Road, Malad (West), Mumbai - 400064

Intermediary/Agent Name & Code (if any): Sandhya Pawar, 1276128

A.Details about Proposer and Policy Period

Name of Proposer: Dhamotharan Kanniyappan
Address of Proposer: NO 3/9 EAST STREET AMARAVATHI PATTINAM Kilambi Krishnapuram,
City/Town: kancheepuram State: Tamil Nadu Pin Code: 631551
Contact No.:(Mobile) 9994195869 Landline:
Email: None PAN Number: GZVPK9364M
AADHAR Number:
Policy to be issued in favour of (list out all the parties who have insurable interest) including the financial institutions
Period of Insurance:
From: To: (No of Years in case of long term policy: 5)
Note: For Long term policy, Period shall not exceed 10 years.
Nomination:
Nominee Name: Bhavani Mathaiya Relationship with the insured: Spouse

B.Covers Opted

Is there any policy in place for the same Yes No

property? If Yes, please provide the details:

Cover/s required:

(When Home Building and Home Contents are opted for, cover for General Contents of Home for Sum Insured equal to 20% of the Sum
Insured for Home Building Cover subject to a maximum of 10 Lakh [Rupees Ten Lakh] is automatically provided).

C. Location of Home Building

Location of Home Building - full postal address with Pin Code: 228/2A1, 228/2A1B5, V.No:21, Kilambi VIllage,Comprised in Old
Sy.No:228/2A1, As Per Patta No:522, New Sy.No:228/2A1B5, Kilambi Village, Kanchipuram Taluk, Kanchipuram District- 631 551
City/Town: Kanchipuram State: Tamil Nadu Pin Code: 631501
Is it in a multi-storey building or is it a standalone house?

In case of multi-storey building, please provide the floor number of Your house

Is there a basement to Your house?

CIN:L67200MH2000PLC129408

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 UIN:IRDAN115RP0005V01202021

D. Details of Home Building

Please note:
your Home Building:is a building consisting of a residential unit, having an enclosed structure and a roof, basement (if any) and fixtures
and fittings permanently attached to the floor, walls or roof, like fixed sanitary fittings, electrical wiring and other permanent fittings etc

It also includesadditional structures if they are on the same site, are used as part of Your Home Building:
a) garage, domestic out-houses used for residence, parking spaces or areas, if any;
b) compound walls, fences, gates, retaining walls, internal roads;
c) verandah or porch and the like;
d) septic tanks, bio-gas plants, fixed water storage units or tanks, solar panels, wind turbines and air conditioning systems, central
heating systems and the l ike, if not included in Home Contents Cover, any other structure.
Sum Insured (SI) for Home Building:

Please note the following: (The amount required to construct Your Home Building at the policy Commencement Date. This
amount is calculated as follows:
a). For residential structure of Your Home including fittings and fixtures: Carpet area of the structure in square metres X Rate of
Cost of Construction at the policy Commencement Date
a. SI for residential structure of Your Home including fittings and fixtures (in ₹):
The Rate of Cost of Construction is the prevailing rate of cost of construction of Your Home Building at the policy Commencement
Date.
b). For additional structures: the amount that is based on the prevailing rate of cost of construction at the Policy Commencement Date.)
b. SI for additional structures (in ₹):

Additional Structure Sum Insured (in ₹)

Carpet area of structure of Home in square metres:

Rate of Cost of Construction per square metre at the policy Commencement Date:

Other Details
Age of the Less than 5 years 5-10 years 10-20 years Above 20 years
building:

Construction Details: Wall Kutcha Pucca Floor Kutcha Pucca Roof Kutcha
Pucca (*strike out what is not applicable)

Please note the following: (Building(s) having walls and/or roofs of wooden planks/thatched leaves and/or grass/hay of any
kind/bamboo/plastic cloth/asphalt/ canvas/tarpaulin and the like are treated as Kutcha Construction. Construction other than Kutcha
Construction is a ‘Pucca Construction’)

E. Details of Home Contents

Please note the
following:

1. Home Contents refer to articles or things in Your Home that are not permanently attached or fixed to the structure of Your Home.
Home Contents may consist of General Contents and/or Valuable Contents.
2. General Contents are all the contents of household use in Your Home, e.g., furniture, electronic items and goods, antennas, solar
panels, water storage equipment, kitchen equipment, electrical equipment (including those fitted on walls), clothing and apparel
and items of similar nature.
3. Valuable Contents of Your Home consist of items such as jewellery, silverware, paintings, works of art, antique items, curios and
items of similar nature.
4. If You have opted for Home Building and Home Contents cover, the General Contents of Your home equal to 20% of the Sum
Insured for Home Building Cover subject to a maximum of `10 Lakhs (Rupees Ten Lakh) are automatically covered.

CIN:L67200MH2000PLC129408

For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666
 UIN:IRDAN115RP0005V01202021

If You want to opt out of in-built cover for General Contents as mentioned in (iv) above and want to have higher Sum Insured
Or

If You have opted for Home Contents Only cover, please provide item wise Sum Insured for General Contents.

(Sum Insured represents Cost of Replacement)

Item wise Sum Insured for General Contents (in ₹):

Items Sum Insured

Furniture, Fixtures and Fittings (Home Furnishings)
Electrical/Electronic
Others
In case of Basement, If there are contents in it, please provide the Sum Insured

F. In-Built Covers
(Loss of Rent & Rent for Alternative Accommodation)
Cover for (Please ✓)

Loss of Rent:

I. Sum Insured: II. Number of Months:

Rent for Alternative Accommodation:

I. Sum Insured: II. Number of Months:

G. Optional Covers
(available on payment of additional premium)

Do You require 'Personal Accident Cover' for Yourself and Your spouse? Yes No
If Yes,

Name & age of Your spouse:

Your age:

Do You require 'Cover for Valuable Contents on Agreed Value Basis (under Home Contents cover)'

Yes No

If Yes, please attach list of items and Sum Insured:

Valuation certificate attached? Yes No

(Valuable Contents of Your Home consist of items such as jewellery, silverware, paintings, works of art, antique items, curios and items of
similar nature.)

(You have to submit a Valuation Certificate. However, the requirement of valuation certificate is waived if the Sum Insured opted for is
upto ₹5 Lakh and Individual item value does not exceed ₹1 Lakh).

CIN:L67200MH2000PLC129408

For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666

UIN:IRDAN115RP0005V01202021

H. Additional/Add-on Covers
(over and above optional covers available on payment of additional premium)
Sl.No Name of Add-on cover Sum insured
1.
2.
3.
4.
5.

I. Premium Details

Mode of Payment
Payment Details
Amount (in ₹)

J. Claims details
Please specify details of any loss to the proposed Property in last 3 years:
SI.No Date of Loss Cause of Loss Claimed Amount Settled Amount/please specify if claim is outstanding
1.
2.
3.
4.
5.
6.

K. Declaration by Insured
I/ We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my / our knowledge and belief and
I / We hereby agree that this declaration shall form the basis of the contract between me/us and the

If any additions or alterations are carried out in the risk proposed after the submission of this proposal form, then the same should be
conveyed to the insurers immediately.

Date:

Place:

signature:

INSURANCE ACT 1938 SECTION 41- Prohibition of Rebates

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 a policy accept any rebate, except such
rebate as may be allowed in accordance with the published prospectus or tables of the insurer.

ANY PERSON MAKING DEFAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH
FINE WHICH MAY EXTEND TO TEN LAKHS RUPEES.

CIN:L67200MH2000PLC129408

For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666

UIN:IRDAN115RP0005V01202021
 Mailing Address: Interface Building No. 16, 601-602, 6th Floor, New Link Road, Malad (West), 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 customersupport@icicilombard.com • Toll Free No.: 1800 2666 • Chargable No.: +91 86 55 222
666
Insurance is the subject matter of solicitation. IRDA Reg. No. 115.CIN: L67200MH2000PLC129408

CIN:L67200MH2000PLC129408