{"id":1358,"title":"ERRORS & OMISSIONS 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/commercial/errors-and-ommissions-insurance/claim-form.pdf","sha256":"21d3000f676eca2e6c6189ad680167c6926bb900b1ea36af7df02adadfb86a7b","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for filing a claim under the Errors & Omissions Insurance policy and must be completed and signed by a Director, Partner, or Principal of the Insured.","notes":["The form must be completed and signed by a Director, Partner or Principal of the Insured.","Appointment of legal representatives should not occur without prior consent of Universal Sompo General Insurance Co. Ltd.","If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later."],"title":"ERRORS & OMISSIONS INSURANCE POLICY CLAIM FORM","submit":{"to":"Universal Sompo General Insurance Co. Ltd.","how":"","address":""},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Full name of insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registered address of insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include area code if applicable","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"B. DETAILS OF CLAIMANT","fields":[{"help":"","type":"text","label":"Full name of Claimant or potential claimant (i.e. party claiming against you)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Complete address of claimant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include area code if applicable","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"C. DETAILS OF INSURED’S CONTRACT WITH CLAIMANT","fields":[{"help":"Describe the services contracted","type":"text","label":"What were you retained or contracted to do (details of services)","options":[],"required":null,"pdf_field":""},{"help":"Attach contract copy if available","type":"text","label":"Were your retainership / contract evidenced in writing? If so, please attach a copy, otherwise, please provide appropriate particulars","options":[],"required":null,"pdf_field":""},{"help":"Describe the work related to the claim","type":"text","label":"What work/services are performed on which the claim arises or may arise","options":[],"required":null,"pdf_field":""},{"help":"Date or period of work","type":"date","label":"When did you perform the work on which the claim arises or may arise","options":[],"required":null,"pdf_field":""},{"help":"Provide full name, designation and work profile","type":"text","label":"Name, designation work profile of the person within your company who performed the work or against whom the claim or potential claim is directed","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"D. DETAILS OF CLAIM","fields":[{"help":"Describe the claim or circumstances in detail","type":"text","label":"What is the precise nature of the claim (i.e. the claimant’s allegations on the insured) or the circumstances which might give rise to a potential claim","options":[],"required":null,"pdf_field":""},{"help":"Date of first awareness and attach correspondence if any","type":"date","label":"On which date did you first become aware of the claim or the circumstances leading to a claim. If received by you in writing, please provide a copy of the correspondence. If oral, please give a first person account of the conversation","options":[],"required":null,"pdf_field":""},{"help":"Specify claimed amount and breakup if possible","type":"amount","label":"What amount is being claimed Please provide breakup, if available","options":[],"required":null,"pdf_field":""},{"help":"Provide your response and opinion on claim amount","type":"text","label":"What are your comments in response to the claim and your opinion on the quantum of claim","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant information and documents","type":"text","label":"Are there any other details that you might wish to share with USGIC or which could be of interest so that We might have a better understanding of the circumstances leading to the claim. Please provide documents, if any.","options":[],"required":null,"pdf_field":""},{"help":"Details of legal representative if engaged","type":"text","label":"As of now, have you engaged any legal representative to act for you. If so, please provide name, firm, address and charge out rates","options":[],"required":null,"pdf_field":""}],"filled_by":"Insured"},{"title":"E. DECLARATION AND AUTHORIZATION","fields":[{"help":"Signature of Director, Partner or Principal","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Print full name of the signatory","type":"text","label":"Full Name of Person Signing","options":[],"required":true,"pdf_field":""},{"help":"Designation of the signatory","type":"text","label":"Designation of the Person Signing","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"Insured"}],"deadlines":["Notify the Company without delay as soon as Loss or Damage has become known"],"applies_to":"Errors & Omissions Insurance claims","attachments":["Copy of retainership / contract if evidenced in writing","Copy of correspondence if claim awareness was in writing","Documents relevant to the claim as mentioned"],"declarations":["The insured guarantees the truthfulness of the statements and understands that false or fraudulent statements may lead to policy cancellation and reservation of rights.","The Company may verify identity, address, facts, and documents with third parties or service providers.","The insured agrees to the Company's privacy policy as amended from time to time.","The insured understands the requirement to submit all necessary documents to avoid delays in claim processing.","The insured declares that all persons having an interest in the property are disclosed and no other claim for the same loss has been made with any other insurer.","The insured consents to verification of identity/address/bank details through Central KYC Registry, UIDAI, or other modes for KYC purposes."],"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/1358-errors-and-omissions-insurance-policy-claim-form"}