{"id":1329,"title":"Claim Form – Failed Well Insurance","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/Rural%20%26%20Social%20-%20Failed%20Well%20Insurance_2.pdf","sha256":"5d3322d9e0725cba807056b4f8a5ccbf3a2436bc2fbb315648fad5b8b2c5f96f","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders to claim insurance for failed wells under the Failed Well Insurance policy.","notes":["The issue of this Form does not constitute admission of liability.","Expenses incurred towards boring/digging include drilling, transportation of equipment if not included in drilling cost, labour charges for fixing casing pipe, yield testing charges if agreed, cleaning and dewatering charges, and spot investigation charges.","Expenses do not include cost of pumping equipment and accessories, cost of casing, site selection cost, and cost of supervision.","An item-wise account of expenditure incurred must be submitted."],"title":"Claim Form – Failed Well Insurance","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured and Policy 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":"Enter the full name of the insured person","type":"text","label":"Name of the Insured (in full)","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the insured","type":"text","label":"Address (in full)","options":[],"required":null,"pdf_field":""},{"help":"Enter the business or occupation of the insured","type":"text","label":"Business / Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter names of financiers or banks involved","type":"text","label":"Name of Financiers / Bank interested in the risk (Agriculture Credit Institutions)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Location of Wells Covered","fields":[{"help":"Enter the state where the wells are located","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter the district of the wells","type":"text","label":"District","options":[],"required":null,"pdf_field":""},{"help":"Enter the village or taluk","type":"text","label":"Village / Taluk","options":[],"required":null,"pdf_field":""},{"help":"Enter the survey or land number","type":"text","label":"Survey No. / GAT No. / HISSA No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the name in which the land is registered","type":"text","label":"Land registered in the name of :","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Types of Wells Covered and Sum Insured","fields":[{"help":"Enter sum insured for shallow tube wells","type":"amount","label":"Shallow Tube wells","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured for filter points","type":"amount","label":"Filter Points","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured for dug wells","type":"amount","label":"Dug Wells","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured for bore wells","type":"amount","label":"Bore wells","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured for dug-cum-bore wells","type":"amount","label":"Dug-cum-Bore wells","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured","type":"amount","label":"TOTAL SUM INSURED :","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Period of Insurance","fields":[{"help":"Enter the start date of insurance period","type":"date","label":"FROM","options":[],"required":null,"pdf_field":""},{"help":"Enter the end date of insurance period","type":"date","label":"TO","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Construction of Wells","fields":[{"help":"Enter number or details as applicable","type":"number","label":"Shallow Tube wells in alluvial position","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Shallow Tube wells in hard rock formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Filter point in alluvial formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Bore well in hard rock formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Dug well in alluvial formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Dug well in hard rock formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Dug-cum-Bore well in alluvial formation","options":[],"required":null,"pdf_field":""},{"help":"Enter number or details as applicable","type":"number","label":"Dug-cum-Bore well in hard rock formation","options":[],"required":null,"pdf_field":""},{"help":"Describe the method used for yield testing","type":"text","label":"Method of testing done for ‘Yield’ test","options":[],"required":null,"pdf_field":""},{"help":"Provide values for water quality parameters if applicable","type":"text","label":"In the case of bad quality of water, what is / are the values of electrical conductivity, residual sodium carbonate and boron","options":[],"required":null,"pdf_field":""},{"help":"Indicate if site approval is obtained and attach certificate if yes","type":"yes-no","label":"Whether the site/s is/are approved for digging by the Department of Hydrology (State Government Ground Water Organisation) ? If so, please attach a copy of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if local authority permission is obtained and attach certificate if yes","type":"yes-no","label":"Whether permission from the local Panchayat / Municipal Authority has been obtained for digging the well/s ? If so, please attach a certified copy of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter diameter of the well","type":"number","label":"Diameter","options":[],"required":null,"pdf_field":""},{"help":"Enter depth of the well","type":"number","label":"Depth","options":[],"required":null,"pdf_field":""},{"help":"Enter yield of water","type":"number","label":"Yield of Water","options":[],"required":null,"pdf_field":""},{"help":"Indicate if geophysical survey was done and attach certificate if yes","type":"yes-no","label":"Whether the wells were constructed after proper geophysical survey by Government or other Approved Agency ? If so, please attach a copy of their Certificate or Survey Report.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Loss","fields":[{"help":"Specify the yield test method used","type":"text","label":"What was the method adopted to test ‘yield’ i.e., whether by ‘V-notch’ method or Compressor method ?","options":[],"required":null,"pdf_field":""},{"help":"Select the season during which yield test was done","type":"choice","label":"Season during which ‘yield’ test was conducted i.e., whether ‘Rabi’ or ‘Kharif’ (Monsoon or Non-Monsoon) Season ?","options":["Rabi","Kharif","Monsoon","Non-Monsoon"],"required":null,"pdf_field":""},{"help":"Enter water yield quantity in gallons per hour","type":"number","label":"What was the quantity of water ‘yield’ during the test in terms of gallons per hour ?","options":[],"required":null,"pdf_field":""},{"help":"Describe parameters used to assess success or failure","type":"text","label":"If the potential in the area or site is generally high, the parameters adopted to find out whether the digging / boring of the well/s was successful or whether the failure was partial or total.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss is due to policy exclusions","type":"yes-no","label":"Whether the loss i.e., failure of ‘yield’ is due to any of Exclusions under the Policy or NABARD Scheme ?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Quantum of Loss / Claim","fields":[{"help":"Enter actual expenditure amount","type":"amount","label":"What was the amount of expenditure actually incurred towards boring / digging of the well/s ?","options":[],"required":null,"pdf_field":""},{"help":"Enter margin money or subsidy amount and source","type":"amount","label":"What is margin money or subsidy received or receivable and the source thereof ?","options":[],"required":null,"pdf_field":""},{"help":"Enter outstanding loan amount","type":"amount","label":"What is the loan amount outstanding in the loan account ?","options":[],"required":null,"pdf_field":""},{"help":"Enter admissible claim amount","type":"amount","label":"Amount of Claim admissible :","options":[],"required":null,"pdf_field":""},{"help":"Enter claim amount payable after policy excess deduction","type":"amount","label":"Amount of Claim payable after deducting the Policy excess :","options":[],"required":null,"pdf_field":""},{"help":"Indicate if loss is certified by financing bank and attach certificate if yes","type":"yes-no","label":"Whether the loss is certified by the financing Bank ?  If so, please attach a certified copy of the Certificate.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declarations and Signatures","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured / Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter place of countersignature","type":"text","label":"COUNTERSIGNED BY AUTHORISED PERSON OF FINANCING BANK OR AGENCY : Place","options":[],"required":null,"pdf_field":""},{"help":"Authorised person of financing bank to sign","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of countersignature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter full name and official seal of authorised person","type":"text","label":"Full Name with Official Seal","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder and financing bank"}],"deadlines":["Please return this Form duly completed within 14 days of the loss together with the relevant documents."],"applies_to":"Failed Well Insurance","attachments":["Copy of approval from Department of Hydrology (State Government Ground Water Organisation) if site approved","Certified copy of permission from local Panchayat / Municipal Authority if obtained","Certificate or Survey Report of geophysical survey by Government or other Approved Agency if applicable","Certified copy of Certificate from financing Bank certifying the loss"],"declarations":["The statements made in the claim form are true to the best of the claimant's knowledge and belief.","No material information bearing upon the claim has been withheld."],"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/1329-claim-form-failed-well-insurance"}