{"id":1391,"title":"Claim Form - Machinery Breakdown Insurance Policy (Commercial)","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/machinery-breakdown-policy/claim-form.pdf","sha256":"b9a5376d5a4f575747c38394b33be3b01a7cd1c83ec778ad716cf9e9742e575c","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim under the Machinery Breakdown Insurance Policy for commercial machinery. The policyholder or claimant fills it.","notes":["If any detail or information is not readily available, do not delay dispatch of this form; such particulars may be sent later.","Submit job-work estimates and pro-forma invoices if repair is in-house.","Attach copy of other insurance policy if applicable."],"title":"Claim Form - Machinery Breakdown Insurance Policy (Commercial)","submit":{"to":"Universal Sompo General Insurance Company Ltd.","how":"","address":"Email: contactclaims@universalsompo.com\nToll free: 1-800-12-4030\nHelpline: 012-26748600"},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Policy to.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim to.","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of insured","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of insured","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Describe what caused the loss or damage","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":"INFORMATION TO AUTHORITY","fields":[{"help":"Indicate if any authority has been informed","type":"yes-no","label":"Have any authority/ been informed about Accident / Loss? If\"Yes\", specify /","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Name of the authority or contact person informed","type":"text","label":"Name of the Authority/ 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":"Address of the authority","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of the authority","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of authority","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of authority","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of authority","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of authority","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of authority","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of authority","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"WITNESS DETAILS","fields":[{"help":"Indicate if any witness is available","type":"yes-no","label":"Is any witness available for accident / loss! If \"Yes\", specify/","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Name of the witness","type":"text","label":"Name of the witness","options":[],"required":null,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of witness","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of witness","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of witness","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of witness","type":"phone","label":"Mobile to.","options":[],"required":null,"pdf_field":""},{"help":"Email of witness","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Limits of Indemnity under the Policy","fields":[{"help":"Policy coverage period","type":"date","label":"Period of Insurance From _ _ /_ _ /_ _ _ _ To _ _ /_ _ /_ _ _ _","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"C. DETAILS OF OTHER INSURANCE","fields":[{"help":"Indicate if other insurance covers the loss","type":"yes-no","label":"Is the Loss/damage covered under any other Insurance? If\"Yes\", specify details and attach copy of policy","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of other insurer","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other insurer","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of other insurer","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline number of other insurer","type":"phone","label":"Landline No.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other insurer","type":"phone","label":"Mobile to.","options":[],"required":null,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Period of other insurance coverage","type":"date","label":"Period of Insurance From / / To / /","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other insurance","type":"amount","label":"Amount of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","fields":[{"help":"Indicate if insured is sole owner","type":"yes-no","label":"Is the insured sole owner of the property? If\"No\", specify/","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe insured's interest in property","type":"text","label":"Nature of Insured interest","options":[],"required":null,"pdf_field":""},{"help":"Name(s) of other interested persons","type":"text","label":"Person/s who has interest on property","options":[],"required":null,"pdf_field":""},{"help":"Nature of interest of other persons","type":"text","label":"His nature of interest","options":[],"required":null,"pdf_field":""},{"help":"Address of other interested persons","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of other interested persons","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of other interested persons","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other interested persons","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of other interested persons","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of other interested persons","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other interested persons","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other interested persons","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Indicate if repair is in-house and submit estimates if yes","type":"yes-no","label":"Is the repair being carried out In-house? If “Yes”, specify submit job-Work Estimates along with Pro-forma Invoices of Spare Parts to be replaced","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of external repairer","type":"text","label":"Name of the Repairer","options":[],"required":null,"pdf_field":""},{"help":"Contact person at repairer","type":"text","label":"Name of the Contact person","options":[],"required":null,"pdf_field":""},{"help":"Address of repairer","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"Address of repairer","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of repairer","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of repairer","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of repairer","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of repairer","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of repairer","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of repairer","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF ITEMS AFFECTED","fields":[{"help":"Provide details of each affected equipment in the columns listed","type":"table","label":"SL. No., DESCRIPTION OF EQUIPMENT, MAKER NAME, YEAR OF MAKE, SL.NO./ MACHINE NO., SUM INSURED RS., DATE OF LAST MAINTENANCE, EXPIRY OF AMC/ WARRANTY, COST OF REPAIRS/ REPLACEMENT","options":[],"required":null,"pdf_field":""},{"help":"Indicate if equipment was repaired before","type":"yes-no","label":"Has the affected equipment undergone any repairs previously?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe previous repairs if any","type":"text","label":"If “Yes”, the nature of such repairs","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF REPAIR","fields":[{"help":"Date when repair was done","type":"date","label":"Date of repair","options":[],"required":null,"pdf_field":""},{"help":"Describe the repair work done","type":"text","label":"Nature of repair","options":[],"required":null,"pdf_field":""},{"help":"Parts of equipment affected","type":"text","label":"Parts affected","options":[],"required":null,"pdf_field":""},{"help":"Cost incurred for repair","type":"amount","label":"Cost of repair","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Year of previous claim","type":"number","label":"Claim Year","options":[],"required":null,"pdf_field":""},{"help":"Description of previous claim","type":"text","label":"Claim Description","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed previously","type":"amount","label":"Amount Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"H. DETAILS OF OTHER INFORMATION","fields":[{"help":"Indicate if you want to provide additional info","type":"yes-no","label":"Do you wish to provide any other information? If\"Yes\", specify/","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Additional information details","type":"text","label":"Specify","options":[],"required":null,"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":"Signature of the insured claimant","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Machinery Breakdown Insurance Policy (Commercial)","attachments":["Copy of other insurance policy if loss/damage is covered under any other insurance","Job-Work Estimates along with Pro-forma Invoices of Spare Parts if repair is in-house"],"declarations":["The insured agrees to provide additional information if required and guarantees truthfulness of 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 or 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/1391-claim-form-machinery-breakdown-insurance-policy-commercial"}