{"id":1029,"title":"Sampurna Udyam Suraksha Policy- Claim Form","purpose":"claim","insurer":{"slug":"oriental-insurance","name":"The Oriental Insurance Company Limited"},"source_pdf":"https://oicl-cms-media.s3.ap-south-1.amazonaws.com/9_Sampurna_Udyam_Suraksha_Claim_Form_de43adc94e.pdf","sha256":"48647bcaee38d1fb56f39799cc3c5cfdb7e811a5ef62b45ff9b56e05c2ea288a","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the insured or claimant to report and claim losses covered under the Sampurna Udyam Suraksha Policy.","notes":["The issuance of this form is not an admission of liability","Attach relevant documents depending on the section(s) / sub-section(s) of loss","The company may require further details or documents depending on the loss section(s)"],"title":"Sampurna Udyam Suraksha Policy- Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"","type":"text","label":"Claim No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance: From ……….To ………. ","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Loss:","options":[],"required":null,"pdf_field":""},{"help":"Full name of insured or claimant","type":"text","label":"1. Name of the Insured/Claimant:","options":[],"required":null,"pdf_field":""},{"help":"Full business address","type":"text","label":"2. Business  Address:","options":[],"required":null,"pdf_field":""},{"help":"Name of financier or other interested party if any","type":"text","label":"3. Name of Financier/Other interest in the property:","options":[],"required":null,"pdf_field":""},{"help":"Specify type of occupancy","type":"text","label":"4. Nature of Occupancy : (specify whether shop, Office, Commercial Enterprise industrial /Non Industrial Unit)","options":[],"required":null,"pdf_field":""},{"help":"Full address where loss/damage occurred","type":"text","label":"5. Location of Loss/Damage : Please mention full address","options":[],"required":null,"pdf_field":""},{"help":"Name of contact person at loss location","type":"text","label":"6. Contact Details of Persons at Loss Location: Name :","options":[],"required":null,"pdf_field":""},{"help":"Designation of contact person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Contact phone numbers","type":"phone","label":"Landline & Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email address of contact person","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss and damage in detail","type":"text","label":"7. Describe the loss with full details of the damage sustained :","options":[],"required":null,"pdf_field":""},{"help":"Date, time and circumstances of loss occurrence","type":"text","label":"a Date and Time of Occurrence of Loss: Please describe the circumstances leading to loss","options":[],"required":null,"pdf_field":""},{"help":"When and how loss was first discovered","type":"text","label":"b On what day, time and how did you first discover the loss:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss was reported to any authority","type":"yes-no","label":"8. Has the Loss been reported to the Authority : YES/NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Reason if loss not reported","type":"text","label":"If No, reason for not reporting the Loss","options":[],"required":null,"pdf_field":""},{"help":"Name and address of authority where loss was reported","type":"text","label":"If Yes, Name & Address of the Authority :","options":[],"required":null,"pdf_field":""},{"help":"Contact numbers of authority","type":"phone","label":"Landline Number & Mobile No. :","options":[],"required":null,"pdf_field":""},{"help":"Email of authority","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"If yes, please provide the following details : Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Insurance period of other policy","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Sum insured or liability limit under other policy","type":"amount","label":"Sum Insured/Limit of Liability","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of other insurance policy","type":"attachment","label":"Please attach the policy copy","options":[],"required":null,"pdf_field":""},{"help":"Details of any previous claims","type":"text","label":"10. Previous claims, if any. Please provide details","options":[],"required":null,"pdf_field":""},{"help":"Details of any recoveries made","type":"text","label":"11. Any recoveries made in respect of the loss :","options":[],"required":null,"pdf_field":""},{"help":"Fill details in table columns as listed","type":"table","label":"12. Details of present claim (attach separate sheet wherever required to elaborate). Sections Type of Insurance Date and Time of occurrence of loss Cause of loss/ accident Brief Description of loss Details of articles damaged/ lost Sum Insured Estimated Loss (Rs) Details of FIR / fire Brigade report","options":[],"required":null,"pdf_field":""},{"help":"Actual value of the damaged/lost property","type":"amount","label":"13. Actual value of the Property :","options":[],"required":null,"pdf_field":""},{"help":"Amount being claimed","type":"amount","label":"14. Amount claimed :","options":[],"required":null,"pdf_field":""},{"help":"Additional information if any","type":"text","label":"15. Any other information that you wish to provide :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured/claimant"},{"title":"Declaration and Signature","fields":[{"help":"Sign here","type":"signature","label":"Signature of the Insured / Claimant","options":[],"required":true,"pdf_field":""},{"help":"Date and place of signing","type":"date","label":"Date & Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/claimant"}],"deadlines":["The form must be completed and returned within 7 days of its receipt"],"applies_to":"claims arising under Sampurna Udyam Suraksha Policy","attachments":["Duly completed claim form","First Information Report and Final Police report, wherever necessary","Fire Brigade Report, wherever necessary","Final Bills of Repair, as applicable","Weather (Meteorological) Report","Copy of other insurance policy if applicable"],"declarations":["The statements made are true to the best of the claimant's knowledge and belief","The articles/property described were damaged/lost under the circumstances described","The articles/property belong to the persons named and no other person has interest in them","If any false or fraudulent statement is made or vital information concealed, the claim will be forfeited and policy void"],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/oriental-insurance/1029-sampurna-udyam-suraksha-policy-claim-form"}