{"id":1408,"title":"Claim Form – Fidelity Guarantee Insurance Policy (Retail)","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/fidelity-guarantee-insurance-policy-retail/claim-form.pdf","sha256":"c846225f9641136dd8bc833318414e70c0c8251cdd41dfdb380fc4386c966f44","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under the Fidelity Guarantee Insurance Policy (Retail). 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.","The issue of this form is not an admission of liability.","Use original documents as required for claim processing.","Contact toll free numbers 1-800-22-4030 / 1800-200-4030 for assistance."],"title":"Claim Form – Fidelity Guarantee Insurance Policy (Retail)","submit":{"to":"Universal Sompo General Insurance Co. Ltd.","how":"","address":"Email: contactclaims@universalsompo.com"},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"Enter the start and end dates of the insurance period","type":"date","label":"Period of Insurance From _ _ /_ _ /_ _ _ _ To _ _ /_ _ /_ _ _ _","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","label":"Is the Loss/damage covered under any other Insurance? If \"Yes\", specify details and attach copy of policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name of other insurer if applicable","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"A. INSURED","fields":[{"help":"Enter policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claim number if any","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. DETAILS OF LOSS","fields":[{"help":"Enter date of loss","type":"date","label":"Date of Loss _ _ / _ _ / _ _ _ _","options":[],"required":null,"pdf_field":""},{"help":"Enter time of loss and select AM or PM","type":"text","label":"Time ______ AM / PM","options":["AM","PM"],"required":null,"pdf_field":""},{"help":"Enter loss location address line 1","type":"text","label":"LOSS LOCATION Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter loss location email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause of loss or damage","type":"text","label":"Describe cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Enter estimated loss amount in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"WITNESS DETAILS","fields":[{"help":"Select if witness is available","type":"yes-no","label":"Is any witness available for accident / loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter witness name if available","type":"text","label":"Name of the witness","options":[],"required":null,"pdf_field":""},{"help":"Enter witness address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter witness address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter witness city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter witness state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter witness pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter witness phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter witness mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter witness email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"INFORMATION TO AUTHORITY","fields":[{"help":"Enter authority name if informed","type":"text","label":"Name of the Authority","options":[],"required":null,"pdf_field":""},{"help":"Enter contact person at authority","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Enter authority reference number","type":"text","label":"Authority reference no.","options":[],"required":null,"pdf_field":""},{"help":"Enter authority address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter authority address line 2","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Enter authority city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter authority state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter authority pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter authority phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter authority mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter authority email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. DETAILS OF OTHER INSURANCE","fields":[{"help":"Enter other insurance address line 1","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter other insurance email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No and provide details if No","type":"yes-no","label":"Is the insured sole owner of the property? If \"No\", specify details","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF OTHER INFORMATION","fields":[{"help":"Select Yes or No and provide other information if Yes","type":"yes-no","label":"Do you wish to provide any other information? If \"Yes\", specify","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance Policy (Retail)","attachments":["Copy of other insurance policy if loss/damage is covered under any other insurance","List of documents received with this claim form as mentioned in the declaration"],"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 has received and understood the list of documents required for claim processing and is responsible for timely submission.","The insured declares details of all persons having interest in the property and confirms no duplicate claims have been made.","The insured consents to verification of identity/address/bank details through Central KYC Registry or UIDAI or other modes."],"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/1408-claim-form-fidelity-guarantee-insurance-policy-retail"}