{"id":1412,"title":"Claim Form - Electronic Equipment 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/electronic-equipment-insurance-retail/claim-form.pdf","sha256":"99f42f6b26d183a4375cd682c88793df446f4b2fd7cb70e111902a0a60bf26d4","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim for loss or damage under the Electronic Equipment 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 to be taken as an admission of liability."],"title":"Claim Form - Electronic Equipment Insurance Policy (Retail)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline 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":"Valid email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Start date of insurance period","type":"date","label":"Period of Insurance From","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe how the loss or damage occurred","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":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Witness Details","fields":[{"help":"Indicate if a 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":"Witness address","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","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":"Pin code of witness","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline phone of witness","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone 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":"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":"","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":"Pin 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":"Start date of other insurance","type":"date","label":"Period of Insurance From","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","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 nature of insured interest","type":"text","label":"Nature of Insured interest","options":[],"required":null,"pdf_field":""},{"help":"Name(s) of other persons with interest","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 person","type":"text","label":"Address line I","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"City of other interested person","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of other interested person","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Pin code of other interested person","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of other interested person","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other interested person","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other interested person","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF ITEMS AFFECTED","fields":[{"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 additional information is provided","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 where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Electronic Equipment Insurance Policy (Retail)","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 carried out 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 all persons with interest in the property are disclosed and 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":3},"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/1412-claim-form-electronic-equipment-insurance-policy-retail"}