{"id":1406,"title":"EMPLOYEES COMPENSATION INSURANCE POLICY (RETAIL) 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/employees-compensation-insurance-policy-retail/claim-form.pdf","sha256":"09dfc63a35177c1577fc45d4a5b1d351fc113e5b86a1b09863127a11d92765fd","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured employer to claim compensation under the Employees Compensation Insurance Policy for an injured employee.","notes":["All questions must be answered fully; use a separate sheet if space is insufficient.","The issue or acceptance of this form is not an admission of liability by the insurer.","Attach copies of police or authority reports if the accident was reported.","The statement of wages must cover the last 12 months or shorter period if employed less than 12 months.","If employed less than 1 month, enter wages paid to another workman for similar work or to the injured employee for the period employed.","For daily wagers, provide daily rate and average number of working days per month.","Use original documents as required for claim processing."],"title":"EMPLOYEES COMPENSATION INSURANCE POLICY (RETAIL) CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. The Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Tel No. Office","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Contact name","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"B. Policy Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end dates","type":"date","label":"Period of Insurance","options":[],"required":true,"pdf_field":""}],"filled_by":"insured employer"},{"title":"C. Injured Person Details","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Local Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Native place address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Father’s name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Occupation for which injured was employed","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nature/description of job being performed by injured person at the time of accident","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is the injured person directly under your employment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If not, for whom and in what capacity the injured was working at the time of accident","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"D. Details of Accident","fields":[{"help":"","type":"date","label":"Date of accident","options":[],"required":true,"pdf_field":""},{"help":"Specify am or pm","type":"text","label":"Time of accident","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place of accident (exact premises/address)","options":[],"required":true,"pdf_field":""},{"help":"Provide date/time and source","type":"text","label":"When did you receive intimation of accident and from whom","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"How did the accident occur","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Are you satisfied that the accident occurred in the course of and arising out of employment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Was the injured person under the influence of drugs or drinks at the time of accident?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Was the injured person guilty of misconduct or disobedience of orders/rules?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain misconduct or disobedience","type":"text","label":"If yes, provide details","options":[],"required":false,"pdf_field":""},{"help":"List names","type":"text","label":"Names of witnesses","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Is the accident reported to Police or any other authority?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach police or authority report if applicable","type":"attachment","label":"If yes, attach a copy of the report.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"E. Details of Injury & Treatment","fields":[{"help":"","type":"text","label":"Nature of injury","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Parts/Regions of body affected","options":[],"required":true,"pdf_field":""},{"help":"Specify left or right side","type":"text","label":"Whether left side or right side","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name & Address of hospital treated at","options":[],"required":false,"pdf_field":""},{"help":"Specify current status","type":"text","label":"Whether still in hospital or discharged","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"What is the medical opinion on nature and extent of disablement?","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Whether returned to work?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"If not, likely date of resumption of duty","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated duration","type":"text","label":"What is the probable period of disablement?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer"},{"title":"Declaration","fields":[{"help":"","type":"signature","label":"Signature of authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Affix company seal","type":"text","label":"Company Seal","options":[],"required":false,"pdf_field":""}],"filled_by":"insured employer or authorized signatory"},{"title":"Statement of Wages","fields":[{"help":"Provide month/year for each row","type":"table","label":"Month and year (Fill in specific dates for each month)","options":[],"required":true,"pdf_field":""},{"help":"Enter wages for each month","type":"table","label":"Wages","options":[],"required":true,"pdf_field":""},{"help":"Enter overtime allowance if any","type":"table","label":"Overtime Allowance","options":[],"required":false,"pdf_field":""},{"help":"Enter bonus if any","type":"table","label":"Bonus","options":[],"required":false,"pdf_field":""},{"help":"Enter value of other allowances","type":"table","label":"Value of food subsidy, free quarters, any other allowance","options":[],"required":false,"pdf_field":""},{"help":"Enter any absence period","type":"table","label":"Period of absence","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of employer/authorized signatory","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Affix company seal","type":"text","label":"Company Seal","options":[],"required":false,"pdf_field":""}],"filled_by":"employer"}],"deadlines":[],"applies_to":"Employees Compensation Insurance Policy (Retail)","attachments":["FIR","Medical certificate/treatment documents","Fitness Certificate","Death certificate","Post Mortem Certificate","Age proof","Statement of witness","Summons from WC Commissioner","Report to Inspector of Labour","Petition"],"declarations":["The insured agrees to provide additional information if required and guarantees the truthfulness of the statements.","The company reserves the right to verify identity, address, facts and documents related to the policy and claim.","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 acknowledges that delays may occur if requirements are not met.","The insured declares that all persons having interest in the property are disclosed and no duplicate claims have been made.","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/1406-employees-compensation-insurance-policy-retail-claim-form"}