{"id":1360,"title":"Claim Form - Cyber Security Insurance","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/cyber-security-insurance/claim-form.pdf","sha256":"e8ce4d8b826d4f596921f94ea452d57eeb05cd5084196e181a600655112446f2","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under their Cyber Security Insurance policy with Universal Sompo General Insurance Company Limited.","notes":["All questions must be answered fully; use separate sheet if needed.","Do not dispose of or destroy damaged property without consent of surveyor or insurer.","The form is not an admission of liability by the insurer.","Make no offer or admission of liability to third parties.","Send any communications regarding the incident to the company immediately.","Use legible copies of documents.","The form must be returned immediately to the company or surveyor."],"title":"Claim Form - Cyber Security Insurance","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Tel No. Office","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Name of a contact person for the claim","type":"text","label":"Contact name","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of the contact person","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email of the contact person","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Policy Details","fields":[{"help":"Policy number as per your insurance documents","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Start date of policy coverage","type":"date","label":"Period of Insurance","options":[],"required":true,"pdf_field":""},{"help":"End date of policy coverage","type":"date","label":"to","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Loss Details","fields":[{"help":"Date when the loss occurred","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of loss with am/pm","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Exact location or address where the loss happened","type":"text","label":"Location/Address of Loss","options":[],"required":true,"pdf_field":""},{"help":"City of loss location","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Postal code of loss location","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"State of loss location","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Description of how the premises are used or occupied","type":"text","label":"Premises occupied as","options":[],"required":true,"pdf_field":""},{"help":"Specify the type of cyber loss","type":"text","label":"Type of Loss","options":[],"required":true,"pdf_field":""},{"help":"Cause or reason for the loss","type":"text","label":"Cause of Loss","options":[],"required":true,"pdf_field":""},{"help":"Detailed description of the cyber-attack incident","type":"text","label":"Describe fully circumstances of Cyber-attack, how it happened","options":[],"required":true,"pdf_field":""},{"help":"Your view on the primary cause of the breach","type":"text","label":"In your opinion what is the main cause of breach","options":[],"required":true,"pdf_field":""},{"help":"Details of your own damage or loss","type":"text","label":"Details Of First Party Loss (Own Damage)","options":[],"required":true,"pdf_field":""},{"help":"Details of any third party loss or damage","type":"text","label":"Third Party Loss Or Damage","options":[],"required":true,"pdf_field":""},{"help":"Details of any third party claim notice received","type":"text","label":"Did you receive notice of claim from third party? If yes please provide","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"D. General","fields":[{"help":"Tick Yes or No; if Yes attach FIR copy","type":"yes-no","label":"Has the loss or damage been reported to the Police?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide insurer name, policy no. and copy of policy","type":"yes-no","label":"Is there any other insurance in force providing cover for this loss or damage?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide date, amount and insurer name","type":"yes-no","label":"Have you ever suffered a loss or damage in the past?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide details","type":"yes-no","label":"Did you take any measures to minimize the loss?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide details (attach separate sheet if needed)","type":"yes-no","label":"Are there any steps taken to prevent a reoccurrence?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide name, address & phone no.","type":"yes-no","label":"Was there another person, in your opinion, responsible for the loss or damage?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide name, address, phone no. and enclose witness statement","type":"yes-no","label":"Was there any witness(es) to the incident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide details of changes/alterations","type":"yes-no","label":"Has there been any alteration in the occupation or use of the premises since the Policy was taken up?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Total amount being claimed","type":"amount","label":"Amount Claimed","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing the declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Cyber Security Insurance claims","attachments":["Legible copy of FIR if loss reported to police","Copy of other insurance policy if applicable","Statement from witness if any","List of documents as received with this claim form"],"declarations":["All information provided is true and no material information is withheld.","The company may 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 understands the list of required documents and that delays may occur if requirements are not met.","All persons having interest in the property are disclosed and no duplicate claims have been made.","Consent is given to verify identity and address proofs through Central KYC Registry, UIDAI or other modes."],"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/1360-claim-form-cyber-security-insurance"}