{"id":1387,"title":"CONSEQUENTIAL LOSS (FIRE INSURANCE 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/consequential-loss-fire-insurance-policy/claim-form.pdf","sha256":"051f05f7e4c5caf8f1ca6d9bd977661b57c19de0d2097557235fe44fcd5c6330","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim consequential loss under a fire insurance policy. The policyholder or their authorized representative fills it.","notes":["If any detail is not readily available, dispatch the form without delay and send particulars later.","The issue of this form is not an admission of liability.","Information about persons responsible for loss will be used only for investigation and not disclosed to suspected parties."],"title":"CONSEQUENTIAL LOSS (FIRE INSURANCE POLICY) - CLAIM FORM","submit":{"to":"","how":"","address":""},"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":""}],"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":false,"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":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Describe the cause briefly","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":"","type":"yes-no","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":false,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address line 1","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Contact person at authority","type":"text","label":"Contact Person","options":[],"required":false,"pdf_field":""},{"help":"Reference number given by authority","type":"text","label":"Authority reference no.","options":[],"required":false,"pdf_field":""},{"help":"Authority address","type":"text","label":"Address line 1","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"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":false,"pdf_field":""},{"help":"City of other insurer","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of other insurer","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Phone number of other insurer","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","fields":[{"help":"Name of other interested party","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Address of other interested party","type":"text","label":"Address line 1","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF CONSEQUENTIAL LOSS","fields":[{"help":"","type":"yes-no","label":"Whether any alteration has been made in the nature of business / occupation of premises after inception of Policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of alteration if any","type":"text","label":"If “Yes”, please give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Were the premises occupied at the time of loss","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date from which premises were unoccupied","type":"date","label":"If no, un-occupied since","options":[],"required":false,"pdf_field":""},{"help":"Reason for un-occupancy","type":"text","label":"for reasons","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer for material damage","type":"text","label":"Details of Material Damage under Fire & Special Perils Policy / MBD Policy Name of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"Address of insurer","type":"text","label":"Address line 1","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone no.","options":[],"required":false,"pdf_field":""},{"help":"Policy number of material damage insurance","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"From and to dates of insurance period","type":"text","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for building","type":"amount","label":"Sum Insured : (a) Building","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for plant and machinery","type":"amount","label":"(b) P&M","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for furniture, fixtures and fittings","type":"amount","label":"(c) FFF","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for stocks","type":"amount","label":"(d) Stocks","options":[],"required":false,"pdf_field":""},{"help":"Select one","type":"choice","label":"At the time of loss, the premises were occupied as :","options":["Manufacturing facility","Warehouse","Dwelling"],"required":null,"pdf_field":""},{"help":"Loss amount for building","type":"amount","label":"Amount of Material Damage loss :(Rs.) (a) Building","options":[],"required":false,"pdf_field":""},{"help":"Loss amount for plant and machinery","type":"amount","label":"(b) P&M","options":[],"required":false,"pdf_field":""},{"help":"Loss amount for furniture, fixtures and fittings","type":"amount","label":"(c) FFF","options":[],"required":false,"pdf_field":""},{"help":"Loss amount for stocks","type":"amount","label":"(d) Stocks","options":[],"required":false,"pdf_field":""},{"help":"From and to dates of business interruption","type":"text","label":"Period for which the business was interrupted due to fire / MBD","options":[],"required":false,"pdf_field":""},{"help":"Annual turnover amount","type":"amount","label":"What was the annual turn-over for the last financial year? Rs.","options":[],"required":false,"pdf_field":""},{"help":"Estimated reduction in turnover","type":"amount","label":"What is the estimated reduction in turn-over due to interruption? Rs.","options":[],"required":false,"pdf_field":""},{"help":"Estimated gross profit loss","type":"amount","label":"What is the estimated loss of Gross Profit due to interruption? Rs.","options":[],"required":false,"pdf_field":""},{"help":"Expenses to minimize loss","type":"amount","label":"Standing Charges / Expenses incurred for Loss Minimization, if any, Rs.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Was there any person / organization, in your opinion, responsible for the loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of responsible party if any","type":"text","label":"If “Yes”, please provide details along with contact numbers and address, if available (this information will be used only for investigation of this claim and source will not be divulged to the suspected party)","options":[],"required":false,"pdf_field":""},{"help":"Describe preventive measures taken","type":"text","label":"What steps have been taken to prevent recurrence of similar incidence?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"F. 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 of previous claim","type":"amount","label":"Amount Rs.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"G. DETAILS OF OTHER INFORMATION","fields":[{"help":"Name of other person with interest","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Address of other person","type":"text","label":"Address line 1","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","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":"Consequential Loss (Fire) Insurance Policy claims","attachments":["List of documents as received with this claim form"],"declarations":["The insured agrees to provide additional information if required and guarantees 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 acknowledges receipt of the list of required documents and understands delays may occur if requirements are not met.","The insured declares all persons with interest in the property are disclosed and no duplicate claims have been made.","The insured consents to verification of identity/address/bank details through official registries 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/1387-consequential-loss-fire-insurance-policy-claim-form"}