{"id":1383,"title":"CLAIM FORM – Directors & Officers 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/directors-and-officers-liability-policy/claim-form.pdf","sha256":"dd1cea0e6e25ec731257da79481a296b36f07c6fb250003e39574d74c83aeebc","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming under the Directors and Officers Liability Insurance Policy. It is to be completed and signed by a Director, Partner, or Principal Officer of the Insured company.","notes":["The form must be completed and signed by a Director, Partner or Principal Officer of the Insured.","Appointment of legal representatives requires prior consent of Universal Sompo General Insurance Co. Ltd.","If any detail or information is not readily available, dispatch the form without delay and send detailed particulars later."],"title":"CLAIM FORM – Directors & Officers Insurance Policy","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"POLICY NUMBER","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured company","type":"text","label":"Policy holder (the company who purchased the policy and in whose name the policy is held)","options":[],"required":null,"pdf_field":""},{"help":"Full registered address","type":"text","label":"Registered address of Insured Organisation","options":[],"required":null,"pdf_field":""},{"help":"State of the registered address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of the registered address","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Contact telephone number","type":"phone","label":"Telephone Number","options":[],"required":null,"pdf_field":""},{"help":"Policy coverage period","type":"text","label":"The policy year/period","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is there any other insurance that may be applicable to the notification?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other applicable insurance","type":"text","label":"If you answered 'Yes' to the above question, please provide details below","options":[],"required":false,"pdf_field":""}],"filled_by":"Director, Partner or Principal Officer of the Insured"},{"title":"Insured Details","fields":[{"help":"List all individuals against whom allegations have been made with these columns","type":"table","label":"Name of individual, Insured entity, Position held with insured entity, Period during which position held, Has the insured Entity indemnified the individual? (Y/N)","options":[],"required":null,"pdf_field":""},{"help":"Describe corporate relationship if applicable","type":"text","label":"If the entity for which the individual worked is a subsidiary of the insured entity, please describe the corporate relationship between the entities (such as “Company B is a wholly owned subsidiary of Company A”, etc.)","options":[],"required":false,"pdf_field":""}],"filled_by":"Director, Partner or Principal Officer of the Insured"},{"title":"Claims Details","fields":[{"help":"Provide chronology, background, dates, nature of allegations, parties involved, responses, and any other relevant details","type":"text","label":"Summary of claim (provide details below)","options":[],"required":null,"pdf_field":""},{"help":"List attached documents such as letter of demand, court documents, investigation reports, etc.","type":"table","label":"Documents Attached with this form","options":[],"required":false,"pdf_field":""}],"filled_by":"Director, Partner or Principal Officer of the Insured"},{"title":"Declaration & Authorization","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized person","type":"signature","label":"Signature of the Authorized Official(s)","options":[],"required":null,"pdf_field":""},{"help":"Company seal if applicable","type":"signature","label":"Seal of the Company","options":[],"required":false,"pdf_field":""}],"filled_by":"Authorized Official(s) of the Insured"}],"deadlines":["Notify the Company without delay as soon as a loss or potential loss causing circumstances become known"],"applies_to":"Directors & Officers Insurance Policy claims","attachments":["Letter of demand (if received)","Letter of service and originating process (if proceedings commenced)","Other court documents (if any)","Documents related to formal investigation (if any)","Investigative reports, internal memorandum or correspondence related to the claim"],"declarations":["The insured guarantees the truthfulness of the statements and understands that false or fraudulent statements may lead to policy cancellation and loss of claim rights.","The Company may verify identity, address, facts, and documents related to the policy and claim with third parties.","The insured agrees to the Company's privacy policy as amended from time to time.","The insured understands that non-submission of required documents or information may delay claim processing and the Company is not responsible for such delays.","The insured declares that all persons having an interest in the property are disclosed and no other claim for the same loss has been made to any other insurer.","The insured consents 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/1383-claim-form-directors-and-officers-insurance-policy"}