{"id":1364,"title":"COMPREHENSIVE OPERATIONAL LARGE RISK 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/comprehensive-operational-large-risk-policy/claim-form.pdf","sha256":"5af5cc23affd7c1165b37db607f3aa3b136ac5ab974e91bd1048094ba7a31da5","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim for losses under the Comprehensive Operational Large Risk Policy. The policyholder fills it to provide details of the loss and related information.","notes":["All questions must be answered fully; use separate sheet if insufficient space.","Incomplete or blank sections will cause the form to be returned.","Do not dispose of or destroy damaged property without consent of surveyor/USGI.","The issue or acceptance of this form is not an admission of liability by USGI."],"title":"COMPREHENSIVE OPERATIONAL LARGE RISK POLICY CLAIM FORM","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":"Provide office and mobile phone numbers","type":"phone","label":"Tel No. Office…………………..                   Mobile………………….","options":[],"required":null,"pdf_field":""},{"help":"Provide email address","type":"email","label":"Email……………………………………","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"B. Policy Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Provide start and end dates of insurance period","type":"date","label":"Period of Insurance to","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"C. Loss Details","fields":[{"help":"Date of loss","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of loss with am or pm","type":"text","label":"Time am/pm","options":[],"required":true,"pdf_field":""},{"help":"Date and time loss was discovered and by whom","type":"text","label":"Date/Time Discovered By whom","options":[],"required":true,"pdf_field":""},{"help":"Full address where loss occurred","type":"text","label":"Location/Address of Loss","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Describe how the premises are occupied","type":"text","label":"Premises occupied as","options":[],"required":true,"pdf_field":""},{"help":"Provide detailed description of the loss event","type":"text","label":"Describe fully circumstances of Loss, how it happened, what caused the Loss","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated loss amounts for each category","type":"amount","label":"Estimated amount of loss 1.Material Damage (Please provide break-up) 2.Business Interruption (due to fire) 3. Business Interruption (due to MLOP)","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"D. General","fields":[{"help":"Tick yes or no; if yes attach FIR/Fire Brigade Report","type":"yes-no","label":"Has the loss or damage been reported to the Police/Fire Brigade? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick yes or no; if yes attach meteorological report or newspaper clipping","type":"yes-no","label":"Has the loss/damage been caused due to flood, earthquake, storm or any other Act of God Yes No","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? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide date, amount of loss and insurer name","type":"yes-no","label":"Have you ever suffered a loss or damage in the past? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick yes or no for each system and indicate if activated during incident","type":"checkbox","label":"Are the premises protected by a Fire Protection/Detection system? Hydrant Yes No Sprinkler Yes No Smoke Detector Yes No Extinguisher(s) Yes No Was the same activated during the incident","options":["Hydrant Yes","Hydrant No","Sprinkler Yes","Sprinkler No","Smoke Detector Yes","Smoke Detector No","Extinguisher(s) Yes","Extinguisher(s) No"],"required":true,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Did you take any measures to minimize the loss? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details or attach separate sheet","type":"yes-no","label":"Are there any steps taken to prevent a reoccurrence? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide name, address & phone no.","type":"yes-no","label":"Was there another person, in your opinion, responsible for the loss or damage? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide name, address, phone no. and enclose witness statement","type":"yes-no","label":"Was there any witness (es) to the incident? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide name & address of relevant parties/financial institution","type":"yes-no","label":"Is the property subject to a hire purchase or hypothecation agreement? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details of changes/alterations in occupation","type":"yes-no","label":"Has there been any alteration in the occupation or use of the premises since the Policy was taken up? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If no, provide since when unoccupied","type":"yes-no","label":"Were the premises occupied at the time of the loss or damage? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If no, provide details of other interested parties","type":"yes-no","label":"Are you the sole owner of the premises/property? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you responsible for repairs? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide total value of all property at premises","type":"amount","label":"At the time of loss, what was the total value of all property in the premises?","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration","fields":[{"help":"Sign the form","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":"policyholder"}],"deadlines":[],"applies_to":"Claims under the Comprehensive Operational Large Risk Policy","attachments":["legible copy of FIR/Fire Brigade Report if loss reported to Police/Fire Brigade","copy of report from meteorological department or newspaper clipping if loss caused by Act of God","copy of other insurance policy if other insurance covers the loss","statement from witness(es) if any","details of changes/alterations in occupation if applicable"],"declarations":["I/We agree to provide additional information if required and guarantee truthfulness of statements.","I/We understand the Company may verify identity, address, facts and documents with third parties.","I/We have read and agree to the Company's privacy policy as amended from time to time.","I/We have received and understood the list of documents required for claim processing and accept responsibility for delays due to non-submission.","I/We declare all persons having interest in the property are disclosed and no other claim for the same loss has been made.","I/We consent 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/1364-comprehensive-operational-large-risk-policy-claim-form"}