{"id":1379,"title":"Claim Form - Electronic Equipment Insurance Policy","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/electronic-equipment-insurance/claim-form.pdf","sha256":"90198bb1eddf7982768221e3d4802a5b9c7cbd35316d5b9d563b848d5619f93b","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim for loss or damage under the Electronic Equipment Insurance Policy.","notes":["If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later."],"title":"Claim Form - Electronic Equipment Insurance Policy","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information to Authority","fields":[{"help":"","type":"yes-no","label":"Have any authori/ been informed about Accident / Loss? If\"Yes\", specify","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Authority/ Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Authority/ reference 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":"City","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":"Telephone number","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Witness Details","fields":[{"help":"","type":"yes-no","label":"Is any witness available for accident / loss! If \"Yes\", specify","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the witness","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":"City","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":"Telephone number","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile to.","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Limits of Indemnity under the Policy","fields":[{"help":"Start and end date of insurance period","type":"date","label":"Period of Insurance From _ _ /_ _ /_ _ _ _ To _ _ /_ _ /_ _ _ _","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"A. Insured Details","fields":[{"help":"Policy number or holder name","type":"text","label":"Policy to.","options":[],"required":null,"pdf_field":""},{"help":"Claim number or related info","type":"text","label":"Claim to.","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address line","options":[],"required":true,"pdf_field":""},{"help":"Additional address details","type":"text","label":"Address line","options":[],"required":false,"pdf_field":""},{"help":"City name","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State name","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Explain how the loss or damage occurred","type":"text","label":"Describe cause of Loss/Damage","options":[],"required":true,"pdf_field":""},{"help":"Estimated amount of loss in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Details of Other Insurance","fields":[{"help":"","type":"yes-no","label":"Is the Loss/damage covered under any other Insurance? If “Yes\", specify details and attach copy of policy","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Additional address details","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"City name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State name","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":"Telephone number","type":"phone","label":"Landline No.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile to.","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Start and end date of other insurance","type":"date","label":"Period of Insurance From / / To / /","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Amount of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Questions","fields":[{"help":"","type":"yes-no","label":"Claims lodged during the preceding 3 years","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the insured sole owner of the property? If\"No\", specify","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe ownership or interest in property","type":"text","label":"Nature of Insured interest","options":[],"required":null,"pdf_field":""},{"help":"Name(s) of other interested persons","type":"text","label":"Person/s who has interest on property","options":[],"required":null,"pdf_field":""},{"help":"Describe their interest","type":"text","label":"His nature of interest","options":[],"required":null,"pdf_field":""},{"help":"Address of other interested person","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Additional address details","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"City name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State name","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":"Telephone number","type":"phone","label":"Phone to.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the repair being carried out In-house?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide estimates and invoices if repair is in-house","type":"text","label":"If “Yes”, specify submit job-Work Estimates along with Pro-forma Invoices of Spare Parts to be replaced","options":[],"required":null,"pdf_field":""},{"help":"Provide details of external repairer","type":"text","label":"If “No”, specify/ following details","options":[],"required":null,"pdf_field":""},{"help":"Name of repair company or person","type":"text","label":"Name of the Repairer","options":[],"required":null,"pdf_field":""},{"help":"Contact person at repairer","type":"text","label":"Name of the Contact person","options":[],"required":null,"pdf_field":""},{"help":"Repairer's address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Additional address details","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"City name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State name","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":"Telephone number","type":"phone","label":"Phone to.","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"E. Details of Items Affected","fields":[{"help":"List each affected equipment with all details in columns","type":"table","label":"SL. No., 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":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the affected equipment undergone any repairs previously?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe previous repairs","type":"text","label":"If “Yes”, the nature of such repairs","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"F. Details of Repair","fields":[{"help":"Date when repair was done","type":"date","label":"Date of repair","options":[],"required":false,"pdf_field":""},{"help":"Describe the repair work","type":"text","label":"Nature of repair","options":[],"required":false,"pdf_field":""},{"help":"Parts that were repaired or replaced","type":"text","label":"Parts affected","options":[],"required":false,"pdf_field":""},{"help":"Cost incurred for repair","type":"amount","label":"Cost of repair","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"G. Details of Previous Losses","fields":[{"help":"Year of previous claim","type":"number","label":"Claim Year","options":[],"required":false,"pdf_field":""},{"help":"Description of previous claim","type":"text","label":"Claim Description","options":[],"required":false,"pdf_field":""},{"help":"Amount claimed previously","type":"amount","label":"Amount Rs.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"H. Details of Other Information","fields":[{"help":"","type":"yes-no","label":"Do you wish to provide any other information? If\"Yes\", specify","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Additional information related to claim","type":"text","label":"If \"Yes\", specify","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Electronic Equipment Insurance Policy claims","attachments":["Copy of other insurance policy if loss/damage is covered under any other insurance","Job-Work Estimates along with Pro-forma Invoices of Spare Parts if repair is in-house"],"declarations":["The insured agrees to provide additional information if required and guarantees the truthfulness of the statements.","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 has received and understood the list of required documents and the company is not responsible for delays due to non-submission.","The insured declares all persons having interest in the property are disclosed and no duplicate claims have been made.","The insured consents to verification of identity/address/bank details through Central KYC Registry or UIDAI or other modes for KYC."],"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/1379-claim-form-electronic-equipment-insurance-policy"}