{"id":1376,"title":"BURGLARY 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/burglary-insurance-policy/claim-form.pdf","sha256":"21903a70579add72efd55a6f0b5056abdf6e1c21c4081721a415ec1086df30d6","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim for loss or damage under a burglary insurance policy.","notes":["The issue of this form is not an admission of liability.","If any detail is not readily available, do not delay dispatch of this form; send particulars later.","Use original documents as required for claim processing."],"title":"BURGLARY POLICY - CLAIM FORM","submit":{"to":"Universal Sompo General Insurance Co. Ltd.","how":"","address":"Toll free: 1-800-22-4030 / 1800-200-4030. Email: contactclaims@universalsompo.com"},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance From        /      /  To / /","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. DETAILS OF LOSS","fields":[{"help":"","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Select AM or PM","type":"choice","label":"Time AM / PM","options":["AM","PM"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"LOSS LOCATION Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Describe how the loss or damage occurred","type":"text","label":"Describe cause of Loss/ Damage","options":[],"required":null,"pdf_field":""},{"help":"Estimated amount of loss in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"WITNESS DETAILS","fields":[{"help":"Select Yes or No","type":"choice","label":"Is any witness available for accident/ loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of witness if available","type":"text","label":"If \"Yes\", specify Name of the witness","options":[],"required":null,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Witness city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Witness state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Witness postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Witness phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Witness mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Witness email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"INFORMATION TO AUTHORITY","fields":[{"help":"Name of authority informed","type":"text","label":"If \"Yes\", specify Name of the Authority","options":[],"required":null,"pdf_field":""},{"help":"Contact person at authority","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Reference number given by authority","type":"text","label":"Authority reference no.","options":[],"required":null,"pdf_field":""},{"help":"Authority address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Authority city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Authority state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Authority postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Authority phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Authority mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Authority email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. DETAILS OF OTHER INSURANCE","fields":[{"help":"Select Yes or No","type":"choice","label":"Is the Loss/damage covered under any other Insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide insurer details and attach policy copy","type":"text","label":"If \"Yes\", specify details and attach copy of policy","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Other insurer address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Other insurer city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Other insurer state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Other insurer postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Other insurer phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Other insurer policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Start and end date of other insurance","type":"date","label":"Period of Insurance From _ _/_ _/ To _ _/_ _/","options":[],"required":null,"pdf_field":""},{"help":"Other insurer mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Other insurer email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Amount insured under other policy","type":"amount","label":"Amount of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claims lodged during the preceding 3 years","fields":[{"help":"Select Yes or No","type":"choice","label":"Is the insured sole owner of the property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if not sole owner","type":"text","label":"If \"No\", specify details","options":[],"required":null,"pdf_field":""},{"help":"Names of persons with interest in property","type":"text","label":"Person/s who has interest on property","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","fields":[{"help":"Check if applicable","type":"checkbox","label":"Yes","options":[],"required":null,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"No","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF THE PREMISES WHERE LOSS HAS OCCURRED","fields":[{"help":"Select how premises was occupied","type":"choice","label":"How was the said Premises occupied","options":["Shop"],"required":null,"pdf_field":""},{"help":"Describe if entry or exit was affected","type":"text","label":"Is the entry or exit from the premises affected? If \"Yes\", specify","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Whether the premises was occupied at the time of loss? If \"No\", specify the last occupied details","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date when premises was last occupied","type":"date","label":"Date last occupied","options":[],"required":null,"pdf_field":""},{"help":"Time when premises was last occupied","type":"text","label":"Time last occupied","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are you responsible for repairs of the premises?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is the property covered under Fire Insurance? If \"Yes\", specify","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fire insurance insurer name","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Fire insurer address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Fire insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Amount insured under fire insurance","type":"amount","label":"Amount of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. 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","type":"amount","label":"Amount Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. DETAILS OF OTHER INFORMATION","fields":[{"help":"Any other relevant information","type":"text","label":"Other Information","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of the insured person","type":"text","label":"Name of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Burglary Insurance (Commercial)","attachments":["copy of other insurance policy if loss/damage is covered under any other insurance","list of documents received with this claim form as mentioned in declaration"],"declarations":["I/We agree to provide additional information if required and guarantee truthfulness of statements.","The company may verify identity, address, facts and documents with third parties.","I/We agree to the company's privacy policy as amended from time to time.","I/We understand the company is not responsible for delays due to non-submission of required documents.","I/We declare all persons having interest in the property are disclosed and no duplicate claims exist.","I/We consent to verification of identity/address/bank details through Central KYC Registry or UIDAI."],"dropped_labels":1},"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/1376-burglary-policy-claim-form"}