{"id":1373,"title":"Claim Form- Device Care Extended Warranty","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/device-care-ew/claim-form.pdf","sha256":"541e5896ba8484ecad2a7c507676f03a77cc0d1fc1c7802d9a8e9e7d584bb6b7","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim under the Device Care Extended Warranty policy for loss or damage to insured equipment.","notes":["If any detail is not readily available, dispatch the form without delay and send such particulars later.","The issue of this form is not an admission of liability."],"title":"Claim Form- Device Care Extended Warranty","submit":{"to":"Universal Sompo General Insurance Company Limited","how":"","address":"Email: contactclaims@universalsompo.com\nToll free: 1-800-12-4030\nHelpline: 012-26748600"},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Policy to.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim to.","options":[],"required":null,"pdf_field":""},{"help":"Enter the first line of your address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter the second line of your address","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter your city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter your state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter your postal PIN code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter your landline phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Describe the reason for the loss or damage to the device","type":"text","label":"Describe cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Provide the estimated amount of loss in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. DETAILS OF OTHER INSURANCE","fields":[{"help":"Name of other insurer if any","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"First line of address of other insurer","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Second line of address of other insurer","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of other insurer","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other insurer","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"PIN code of other insurer","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline number of other insurer","type":"phone","label":"Landline No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","fields":[{"help":"Name of other interested party if any","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"First line of address of other interested party","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Second line of address of other interested party","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of other interested party","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other interested party","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"PIN code of other interested party","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other interested party","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other interested party","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF ITEMS AFFECTED","fields":[{"help":"Fill details for each affected item in the columns: Description, Maker Name, Year, Serial No., Sum Insured, Last Maintenance Date, AMC/Warranty Expiry, Repair/Replacement Cost","type":"table","label":"DESCRIPTION OF EQUIPMENT, MAKER NAME, YEAR OF MAKE, SL.NO./MACHINE NO., SUM INSURED RS., DATE OF LAST MAINTENANCE, EXPIRY OF AMC/WARRANTY, COST OF REPAIRS/REPLACEMENT","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the affected equipment undergone any repairs previously?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the previous repairs if any","type":"text","label":"If “Yes”, the nature of such repairs","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF REPAIR","fields":[{"help":"Enter the date when repair was done","type":"date","label":"Date of repair","options":[],"required":null,"pdf_field":""},{"help":"Describe the repair work done","type":"text","label":"Nature of repair","options":[],"required":null,"pdf_field":""},{"help":"List parts that were affected","type":"text","label":"Parts affected","options":[],"required":null,"pdf_field":""},{"help":"Enter the cost of the repair in rupees","type":"amount","label":"Cost of repair","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Year of previous claim","type":"number","label":"Claim Year","options":[],"required":null,"pdf_field":""},{"help":"Description of previous claim","type":"text","label":"Claim Description","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed previously in rupees","type":"amount","label":"Amount Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"H. DETAILS OF OTHER INFORMATION","fields":[{"help":"Enter the place where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Device Care Extended Warranty claims","attachments":["List of documents with this claim form as received by the insured"],"declarations":["I/We agree to provide additional information if required and guarantee the truthfulness of the 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 at www.universalsompo.com.","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 elsewhere.","I/We consent to verification of identity/address/bank details through Central KYC Registry or 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/1373-claim-form-device-care-extended-warranty"}