{"id":1337,"title":"Claim Form – CUM – VETERINARY CERTIFICATE","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-%20Quail%20Insurance_2.pdf","sha256":"7b38b8e1b4b2a6d849eb07a0750acf603df50dabc38b3f768e08ba24947a3cac","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for claiming insurance for bird mortality under Quail Insurance and is filled by the policyholder (farm owner) and the veterinary surgeon.","notes":[],"title":"Claim Form – CUM – VETERINARY CERTIFICATE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"","type":"text","label":"Name of the farm and its location","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of owner(s)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Description of the birds","options":[],"required":null,"pdf_field":""},{"help":"Provide number of dead birds and claim amount","type":"number","label":"A) Number of birds dead for which claim is preferred and the amount claimed","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"B) Breed and strain of birds","options":[],"required":null,"pdf_field":""},{"help":"Date when illness was first noticed","type":"date","label":"A) When were the birds first seen ill?","options":[],"required":null,"pdf_field":""},{"help":"Date notice was sent to vet","type":"date","label":"B) When was notice sent to the Veterinary Surgeon?","options":[],"required":null,"pdf_field":""},{"help":"Dates when vet attended the birds","type":"text","label":"C) Dates of attendance by Veterinary Surgeon","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment and preventive measures","type":"text","label":"D) Whether treatment given or not? If yes, Particulars of treatment given: What are the preventive measures taken to protect other birds?","options":[],"required":null,"pdf_field":""},{"help":"Date when deworming was done","type":"date","label":"E) Date of deworming done","options":[],"required":null,"pdf_field":""},{"help":"Cause of bird deaths","type":"text","label":"F) CAUSE OF DEATH:","options":[],"required":null,"pdf_field":""},{"help":"Mention any disease and egg yield if applicable","type":"text","label":"G) Is there any contagious or infectious disease prevalent in the flocks: or in the vicinity?--- If the birds have started laying give No. of eggs yield for the past 4 weeks","options":[],"required":null,"pdf_field":""},{"help":"Vaccination details with dates and source","type":"text","label":"H) Have all the birds been protected as per vaccination schedule against Ranikhet, Fowl pox, Mareck’s diseases? If so give dates of vaccinations done. Source of receipt of vaccine: date of receipt Brew No.","options":[],"required":null,"pdf_field":""},{"help":"Source of chicks supply","type":"text","label":"A) What was the source of supply of bird/s chicks?","options":[],"required":null,"pdf_field":""},{"help":"Source of feed supply","type":"text","label":"B) What was the source of supply of feed","options":[],"required":null,"pdf_field":""},{"help":"Details of compensation claimed elsewhere","type":"text","label":"In case of any mass mortality, whether any compensation has been claimed from any other source? If so, give details of the No. of birds, amount compensated etc.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if post-mortem done and report enclosed","type":"yes-no","label":"A) Whether Post-Mortem conducted? If so, is a detailed Post-Mortem report enclosed or not?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Number of birds culled","type":"number","label":"B) No of birds culled so far","options":[],"required":null,"pdf_field":""},{"help":"Date of premium payment","type":"date","label":"When was the premium paid?","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Name and signature of witness","type":"signature","label":"Name & Signature of Witness:","options":[],"required":null,"pdf_field":""},{"help":"Signature of the policyholder","type":"signature","label":"Signature of Insured.","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Veterinary Certificate","fields":[{"help":"Number of dead birds examined","type":"number","label":"Total No. of birds died:","options":[],"required":null,"pdf_field":""},{"help":"Mortality percentage","type":"number","label":"Percentage of mortality:","options":[],"required":null,"pdf_field":""},{"help":"Identification number of birds","type":"text","label":"Identity No.","options":[],"required":null,"pdf_field":""},{"help":"Cause of death as per veterinary examination","type":"text","label":"CAUSE OF DEATH:","options":[],"required":null,"pdf_field":""},{"help":"Veterinary surgeon's signature","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Veterinary surgeon's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Date of certificate signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Veterinary surgeon's name and address","type":"text","label":"Name & Address","options":[],"required":null,"pdf_field":""},{"help":"Location of veterinary surgeon","type":"text","label":"Station :","options":[],"required":null,"pdf_field":""}],"filled_by":"veterinary surgeon"}],"deadlines":[],"applies_to":"claims for bird mortality under Quail Insurance","attachments":["Attach a detailed report of P.M. done on a sample batch of carcasses"],"declarations":["The insured warrants the truth of the statements and affirms proper care was given to the birds.","If any false statement or concealment is made, the policy shall be void and rights to recover shall be forfeited.","The veterinary surgeon certifies the examination and cause of death without adverse reflection on care and management."],"dropped_labels":1},"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/1337-claim-form-cum-veterinary-certificate"}