{"id":1380,"title":"Claim Form – Fidelity Guarantee 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/fidelity-guarantee-insurance-policy/claim-form.pdf","sha256":"9727ec209de0deb6c15e2ad302052c62b4719d5e73a971e45cbf84a6d6389b3a","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under the Fidelity Guarantee Insurance Policy for loss or damage covered by the policy.","notes":["If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later.","The issue of this form is not an admission of liability.","Use the exact formats for dates and contact details as indicated.","Attach copies of other insurance policies if applicable."],"title":"Claim Form – Fidelity Guarantee Insurance Policy","submit":{"to":"Universal Sompo General Insurance Company Limited","how":"","address":"Email: contactclaims@universalsompo.com\nToll free: 1-800-22-4030\nHelpline: 022-26748600"},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","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":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Your insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. DETAILS OF LOSS","fields":[{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Specify AM or PM","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"LOSS LOCATION Address line 1","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":"","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":"Briefly 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 Indian Rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is any witness available for accident / loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Full name of witness","type":"text","label":"If \"Yes\", specify Name of the witness","options":[],"required":null,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Witness address","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 address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Name of the authority informed","type":"text","label":"If \"Yes\", specify Name of the Authority","options":[],"required":null,"pdf_field":""},{"help":"Name of 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 1","options":[],"required":null,"pdf_field":""},{"help":"Authority address","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 address","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 name and policy details","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":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","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 of other interested parties","type":"text","label":"If \"No\", specify details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF THE DEFAULTING EMPLOYEE","fields":[{"help":"Provide all relevant details about the employee responsible for the loss","type":"text","label":"Details of the defaulting employee","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF OTHER INFORMATION","fields":[{"help":"Select Yes or No","type":"choice","label":"Do you wish to provide any other information?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide any additional information relevant to the claim","type":"text","label":"If \"Yes\", specify","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance Policy claims","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"],"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 understands delays may occur if requirements are not met.","The insured declares details of all persons having interest in the property and that no other claim for the same loss has been made elsewhere.","The insured consents to verification of identity/address/bank details through Central KYC Registry, UIDAI or other modes for KYC purposes."],"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/1380-claim-form-fidelity-guarantee-insurance-policy"}