{"id":1295,"title":"FIDELITY GUARANTEE INSURANCE - CLAIM FORM","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Fidelity%20Guarantee%20Claim%20Form.pdf","sha256":"3664dd6895261aeecb4a7d223264065ad7f4d7e789cabe4c51736d539c290832","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Fidelity Guarantee Insurance policy by the insured to report loss due to employee defalcation.","notes":["The issue of this form does not constitute admission of liability","If space is not sufficient for describing defalcation, provide details on a separate signed sheet"],"title":"FIDELITY GUARANTEE INSURANCE - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured and Employee Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Name of Insured (in full)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Address","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of the insured's business","type":"text","label":"c) Business","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Name of the defaulting employee in full","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) His present address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Loss and Defalcation Details","fields":[{"help":"Enter the amount of loss in rupees","type":"amount","label":"Amount of loss sustained Rs.","options":[],"required":null,"pdf_field":""},{"help":"Date when the loss was discovered","type":"date","label":"Date of discovery of the defalcation","options":[],"required":null,"pdf_field":""},{"help":"Date or dates when the defalcation occurred","type":"date","label":"Date (s) of defalcation","options":[],"required":null,"pdf_field":""},{"help":"Describe the method of defalcation in detail; attach additional sheet and certified statement as required","type":"text","label":"How exactly was the defalcation committed? If space is not sufficient, please give full and detailed particulars on a separate signed sheet. (Also please attach a certified statement containing all entries in the Insured’s books of accounts relative to the defalcation in the order of their dates)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Duties and Handling of Money and Stock","fields":[{"help":"Describe employee's role related to money","type":"text","label":"a) In what capacity was he engaged and where? Money","options":[],"required":null,"pdf_field":""},{"help":"Explain how money was given to the employee","type":"text","label":"b) In what way did money reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"State the maximum amount held and duration","type":"text","label":"c) What was the largest sum which he held in his hands at any one time and for how long?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if employee was authorized to pay out money","type":"text","label":"d) Was he allowed to pay out any amounts on the Insured’s behalf? If so, details","options":[],"required":null,"pdf_field":""},{"help":"Name the person(s) who authorized payments","type":"text","label":"e) Who authorised these payments or issues?","options":[],"required":null,"pdf_field":""},{"help":"Explain receipt issuance and checking process","type":"text","label":"f) Was he required to give printed receipts from a book with counterfoils? If so, how often were the counterfoils examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"Describe bank deposit and verification process","type":"text","label":"g) Were moneys paid into Bank by the defaulting employee? If so, how often were Bank Books examined and checked and by whom?","options":[],"required":null,"pdf_field":""},{"help":"State allowed cash balance held by employee","type":"text","label":"h) What balance, if any was allowed to be kept in his hand?","options":[],"required":null,"pdf_field":""},{"help":"Describe cash account balancing and verification","type":"text","label":"i) How often were the Cash Accounts balanced and how was their accuracy checked? Please explain fully.","options":[],"required":null,"pdf_field":""},{"help":"State frequency of direct account statements to customers","type":"text","label":"j) How often were accounts sent direct to Customers independently of the employee?","options":[],"required":null,"pdf_field":""},{"help":"Explain employee's responsibility for stock and how stock was handled","type":"text","label":"k) Did the employee have charge of stock? If so, in what way did stock reach his hands?","options":[],"required":null,"pdf_field":""},{"help":"State if employee could issue stock and who authorized if not","type":"text","label":"l) Was he allowed to issue stores or materials independently? If not, who authorised these issues?","options":[],"required":null,"pdf_field":""},{"help":"Frequency of stock checks","type":"text","label":"m) How often was the position of stock handled by the employee checked?","options":[],"required":null,"pdf_field":""},{"help":"Date of last stock check","type":"date","label":"n) When was the last check made?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Audit and Security Details","fields":[{"help":"Provide audit frequency, auditor name, and date of last audit","type":"text","label":"8. How often were the Account Book/ Stock Books at the place of the defaulting employee’s employment audited and by whom? When was the last audit done?","options":[],"required":null,"pdf_field":""},{"help":"List any money or property of employee held by insured","type":"text","label":"9. Has the Insured any moneys, estate, or effects of the employee in his possession? If so, give particulars with amounts.","options":[],"required":null,"pdf_field":""},{"help":"Describe any other security held from employee","type":"text","label":"10. Does the Insured hold any other security from the employee? If so, state its nature and amount.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of employee's family or property","type":"text","label":"11. Is the defaulting employee a member of a joint family, or does he hold any property, furniture or other effects? If so, give details.","options":[],"required":null,"pdf_field":""},{"help":"List names and addresses of employee's near relatives","type":"text","label":"12. Has the employee any near relatives? If so, give their names and addresses, if known.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Actions Taken and Police Report","fields":[{"help":"Describe any legal or disciplinary action taken","type":"text","label":"13. Has the Insured taken any action against the employee? If so, state the nature of action taken.","options":[],"required":null,"pdf_field":""},{"help":"Provide police station details and police action taken","type":"text","label":"14. Has the loss been reported to the Police? If so, state at which Police Station and what action, if any has been taken by them.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date  :","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured:","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Please return the form duly completed within three months of the discovery of the loss"],"applies_to":"Fidelity Guarantee Insurance claims","attachments":["All particulars annexures","Certified statement containing all entries in the Insured’s books of accounts relative to the defalcation in the order of their dates"],"declarations":["The insured declares that the foregoing particulars are true and correct in every respect"],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","fetched_at":"2026-10-20"}],"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/united-india-insurance/1295-fidelity-guarantee-insurance-claim-form"}