{"id":1390,"title":"PRODUCT LIABILITY INSURANCE (COMMERCIAL) 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/products-liability-insurance-policy/claim-form.pdf","sha256":"d1de351a36ba3c204fd52a78799275a531c96a104690a07201d6650d6ccd3847","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to report and claim under the Product Liability Insurance (Commercial) policy for accidents causing injury or damage related to the insured product.","notes":[],"title":"PRODUCT LIABILITY INSURANCE (COMMERCIAL) 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":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Provide details if other insurance policies cover the same incident","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","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 and cause of the accident","type":"text","label":"Describe the accident in detail i.e. how did it occur?","options":[],"required":null,"pdf_field":""},{"help":"State the date/time and source of first information about the accident","type":"text","label":"When did you first come to know of the accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain what was done 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 copy","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":"Date when insurer was first informed of the claim","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","fields":[{"help":"List injured persons with contact and occupation details","type":"text","label":"Has any person/s sustained any injuries in the accident? If so, give name/s, phone numbers and address/es and occupation/s of such person/s.","options":[],"required":null,"pdf_field":""},{"help":"Location of injured persons during the accident","type":"text","label":"State where such person was at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details for injured persons","type":"text","label":"Have the injured persons been moved to the hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Details of claims made against you and attach copies if available","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 details of other authorities informed and attach report copy","type":"text","label":"Has the accident been reported to any other authority? If yes, state to whom and attach copy of the report submitted","options":[],"required":null,"pdf_field":""},{"help":"Describe any actions taken by authorities","type":"text","label":"What action, if any, has been taken by the authority","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amount","type":"amount","label":"Pl. give estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with contact details if available","type":"text","label":"Pl. give if possible, the names, phone number, addresses of all witnesses to the accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Name of the person signing","type":"text","label":"Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Product Liability Insurance (Commercial)","attachments":["Copy of the contract agreement (if contractor involved)","Copy of police report (if police report made)","Copy of notification received and bill (if claim made in writing)","Copy of report submitted to other authority (if applicable)"],"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 understands that non-submission of required documents may delay claim processing.","The insured declares all persons with interest in the property are disclosed and no duplicate claims exist.","The insured consents to verification of identity/address/bank details through official registries 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/1390-product-liability-insurance-commercial-claim-form"}