{"id":1388,"title":"PRODUCT RECALL 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/product-recall/claim-form.pdf","sha256":"878f1d490079be62ce0492302fb43b00ddf367f1150eb032b40d8401c0f0e8fc","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim under the Product Recall Insurance Policy for incidents involving product defects, accidents, injuries, or damages. The insured fills this form to provide details of the claim to the insurance company.","notes":["The issue of this form is not an admission of liability.","Complete and return the form without delay; missing particulars can be sent later.","Attach original documents as required.","Office use only sections are excluded from this form."],"title":"PRODUCT RECALL INSURANCE POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. Details of the Insured","fields":[{"help":"","type":"text","label":"Insured’s Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid phone number","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Do you have any other insurance policies covering in respect to the same incident? If yes, give details of insurer, policy no., etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Particulars of the Accident? (if any)","fields":[{"help":"Provide date and time when the accident occurred","type":"date","label":"Date and time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Specify the location of the accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Explain the circumstances of the accident","type":"text","label":"Describe the accident in detail i.e. how did it occur?","options":[],"required":null,"pdf_field":""},{"help":"State date/time and source of information","type":"text","label":"When did you first come to know of the accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain what you did immediately after learning of the incident","type":"text","label":"Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Provide contractor details and attach contract agreement","type":"text","label":"State name and contractor involved in the incident (if any) and attach a copy of the contract agreement.","options":[],"required":null,"pdf_field":""},{"help":"Provide police report details if applicable","type":"text","label":"Was police report made? If yes, please share details of the report and actions taken by the authority.","options":[],"required":null,"pdf_field":""},{"help":"Provide date when insurer was first notified","type":"date","label":"When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Resultant Injuries and Damages- The Injured Persons and Third-Party Property Damage (if any)","fields":[{"help":"List injured persons with details","type":"text","label":"Has any person/s sustained any injuries in the accident? If so, give name/s, address/es and occupation/s of such person/s.","options":[],"required":null,"pdf_field":""},{"help":"Provide location of injured persons during accident","type":"text","label":"State where such person was at the time of accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Describe property/livestock damage with owner details","type":"text","label":"Has the accident caused damage to property or livestock? If so, give name/s and address/es of the owner/s of the property and/or the livestock and full description of the property and state the nature of and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of claims made against you and attach documents if any","type":"text","label":"Has any claim been made upon you by any person/s? If so, state by whom and give full particulars (If claim has been made in writing, attach a copy of the notification received and of the bill, if submitted)","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated financial loss amount","type":"amount","label":"Estimated amount of loss","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with contact details if available","type":"text","label":"Give, if possible, the names, phone numbers and addresses of all witnesses to the accident","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"D. Potential danger of Bodily Injury or Property Damage from “Your Product”","fields":[{"help":"Explain the product defect and potential risks","type":"text","label":"Describe the defect in detail with the product that can result in bodily injury or property damage?","options":[],"required":null,"pdf_field":""},{"help":"State date/time and source of defect information","type":"text","label":"When did you first come to know of the defect and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain actions taken after learning about the defect","type":"text","label":"Describe in detail your immediate actions taken upon receipt of the above-mentioned defect?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the product recall plan and traceability","type":"text","label":"Please share the recall plan including details with respect to product traceability.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Sign the form","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print your name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Product Recall Insurance Policy claims","attachments":["Copy of the contract agreement (if contractor involved)","Copy of police report (if made)","Copy of notification received and bill (if claim made in writing)"],"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 acknowledges receipt of the list of required documents and understands that non-submission may delay claim processing.","The insured declares all persons with interest in the property are disclosed and no other claim for the same loss has been made with 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/1388-product-recall-insurance-policy-claim-form"}