{"id":1351,"title":"Brackish Water Prawn Insurance Policy - Claim Form","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/brackish-water-prawn-insurance/claim-form.pdf","sha256":"a2209256d86fba4c4eedd025bc33f4d342be26c0b5afac47c5472c484a46985e","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Brackish Water Prawn Insurance Policy. It is filled by the insured prawn farmer and the concerned authority of the State Fisheries Department or MPEDA or BFDA.","notes":["The issue of this form is not to be taken as an admission of liability.","The Death Certificate form must be completed by the concerned authority of the State Fisheries Department or MPEDA or BFDA and forwarded along with the Claim Form.","Amount of claim must be supported by bills.","Use the exact details as per the policy and project records."],"title":"Brackish Water Prawn Insurance Policy - Claim Form","submit":{"to":"the Company","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details and Claim Information","fields":[{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy  No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide a contact number","type":"phone","label":"Telephone No./Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Provide an email address","type":"email","label":"E-mail ID No.","options":[],"required":null,"pdf_field":""},{"help":"Fill details for each tank/project as columns named","type":"table","label":"Details of Project and Claim : Name and Location of the Project, Water area in hectares, Survey Nos, No. & Species of Prawns stacked tank wise, Average weight at the time of Loss, Value prior to loss(input cost)","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of loss","type":"text","label":"Cause of loss with full details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is there any outbreak of epidemic in the vicinity?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date when accident or disease was first noticed","type":"date","label":"Date of occurrence of accident or disease, when seen first.","options":[],"required":null,"pdf_field":""},{"help":"Describe preventive measures taken","type":"text","label":"What are the steps taken to prevent loss after the accident/disease/epidemic?","options":[],"required":null,"pdf_field":""},{"help":"Specify total or partial loss and extent or date","type":"text","label":"(a) Whether the accident or disease caused a total loss of prawns or only a partial loss. If partial loss, then what is the extent of loss? (b)If total, date by which the loss was total","options":[],"required":null,"pdf_field":""},{"help":"Date notice was sent","type":"date","label":"When was the notice sent to the certifying officer?","options":[],"required":null,"pdf_field":""},{"help":"Provide source, date and price details","type":"text","label":"Source and date of purchase of post larvae & price paid.","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If the loss has been due to pollution, poisoning, riot & strike.-give details","options":[],"required":null,"pdf_field":""},{"help":"Enter claim amount supported by bills","type":"amount","label":"Amount of Claim (input Cost) to be supported by Bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Claim Details","fields":[{"help":"Provide details if insured elsewhere or receiving compensation","type":"text","label":"Are prawns insured elsewhere? Are you receiving compensation from any other source? If so, from where?","options":[],"required":null,"pdf_field":""},{"help":"Enter volume before loss","type":"number","label":"Total volume of bunds in cubic metres before loss.","options":[],"required":null,"pdf_field":""},{"help":"Provide volume details separately","type":"text","label":"Volume of earth washed away. Give working separately(tank wise & bunds wise)","options":[],"required":null,"pdf_field":""},{"help":"Provide measurements if breaches exist","type":"text","label":"Measurement of breaches, if any.","options":[],"required":null,"pdf_field":""},{"help":"Enter repair cost","type":"amount","label":"Cost of repairs of bunds","options":[],"required":null,"pdf_field":""},{"help":"Enter rate per cubic metre","type":"amount","label":"Rate paid for cubic metre of earth work.","options":[],"required":null,"pdf_field":""},{"help":"Enter total claim amounts separately","type":"amount","label":"Total Claim : (a) Prawn (b) Bunds","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Death Certificate (to be filled by State Fisheries Department or MPEDA or BFDA)","fields":[{"help":"","type":"date","label":"Date on which the intimation of disease or loss/accident received from the Owner of the farm","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Mode of information to you by the Owner","options":[],"required":null,"pdf_field":""},{"help":"Date(s) of inspection","type":"date","label":"Dates of your inspection of the farm","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Species of Prawn/Shrimp","options":[],"required":null,"pdf_field":""},{"help":"Age of prawns/shrimps","type":"text","label":"Age at the time of death /loss","options":[],"required":null,"pdf_field":""},{"help":"Average weight in grams","type":"number","label":"Average weight in grams at the time of death/loss","options":[],"required":null,"pdf_field":""},{"help":"Value based on expenses","type":"amount","label":"Value at the time of death (in terms of incurred expenses)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Specify total or partial loss and approximate percentage if partial","type":"text","label":"Whether the loss is total or partial (if partial specify in terms of approximate percentage)","options":[],"required":null,"pdf_field":""},{"help":"Opinion on care and precautions","type":"text","label":"In your opinion whether the prawns are cultured had all the care and attention and all the necessary precautions been taken to avert the loss","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of certifying authority","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Provide full details of certifying authority","type":"text","label":"Name, Qualification, Designation & Address","options":[],"required":null,"pdf_field":""}],"filled_by":"concerned authority"}],"deadlines":["This form should be completed without delay and forwarded to the Company alongwith the Claim Form."],"applies_to":"Brackish Water Prawn Insurance Policy claims","attachments":["Bills supporting the Amount of Claim (input Cost)","Death Certificate completed by the concerned authority"],"declarations":["The insured agrees to provide additional information if required and guarantees the truthfulness of the statements.","The Company reserves the right to verify identity, address, facts and documents with third parties.","The insured agrees to the Company's privacy policy as amended from time to time.","The insured has received and understood the list of documents required for claim processing and acknowledges that delays due to non-submission are not the Company's responsibility.","The insured declares that details of all persons having interest in the property are provided and no other claim for the same loss has been made.","The insured consents to verification of identity/address/bank details through Central KYC Registry or UIDAI or other modes for KYC purposes.","The certifying authority certifies the correctness of answers, proper maintenance of books, and that death has no adverse reflection on care and management.","The certifying authority confirms physical verification of dead prawns and may specify any relevant information or difference of opinion."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"contactclaims@universalsompo.com","label":"Claims Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"e Claim Details\nTPA’s Servicing Group Health Insurance\nDownload Pulz App\nConnect with Us\ncontactus@universalsompo.com\ncontactclaims@universalsompo.com\nHealth Insurance :\nComplete Healthcare Insurance\nA Plus Health Insurance\nSaral Suraksha Bima\nGroup Mashak Rakshak Polic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contactus@universalsompo.com","label":"Theft Claim Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"ntimate claim.\nFor\nTheft Claim\n, please connect with us on below details.\nPhone:\n1800-22-4030\n,\n1800-200-4030\nor\nEmail:\ncontactus@universalsompo.com\nOk\nView All Policies\nHealth Insurance\nComplete Healthcare Insurance\nSuper Healthcare Insurance\nArogya SanjeevaniInsuran","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-22-4030","label":"Claims Toll Free Number (MTNL/BSNL Lines)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":null,"fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022-41582900 - 41582999","label":"Claims Helpline Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":"tactclaims@universalsompo.com 2. Call on our Toll Free number 1-800-22-4030 (from MTNL & BSNL Lines) 3. Helpline number 022-41582900 - 41582999\nIn case of telephonic contact, our call centre executive shall note down the basic requirements and pass on the informa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-4030","label":"Motor Claim Intimation Toll Free","level":null,"hours":"24/7","applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"Motor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-5142","label":"Crop Helpline Number","level":null,"hours":null,"applies_to":"crop","source_url":"https://www.universalsompo.com/claimintimation/","quote":"otor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin\nI am a Customer\nI am an Agent\nP","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/universal-sompo-general-insurance/1351-brackish-water-prawn-insurance-policy-claim-form"}