{"id":1417,"title":"CONSEQUENTIAL LOSS (FIRE 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/consequential-loss-fire-insurance-policy-Retail/claim-form.pdf","sha256":"ddc0aa0a4be6f163071d2eeb0ce95c69f0191890f6ac0506fce8041b69230528","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured policyholder to claim consequential loss under the Fire Insurance Policy (Retail).","notes":["If any detail is not readily available, dispatch the form without delay and send particulars later.","The issue of this form is not an admission of liability."],"title":"CONSEQUENTIAL LOSS (FIRE INSURANCE POLICY) - RETAIL - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. DETAILS OF LOSS","fields":[{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Specify time and AM or PM","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"LOSS LOCATION Address line 1","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":"Enter 6 digit postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"10 digit mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe the cause","type":"text","label":"Describe cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Estimated amount in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"WITNESS DETAILS","fields":[{"help":"","type":"choice","label":"Is any witness available for accident / loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if witness is available","type":"text","label":"If \"Yes\", specify Name of the witness","options":[],"required":null,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Witness city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Witness state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Witness postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Witness phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Witness mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Witness email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"INFORMATION TO AUTHORITY","fields":[{"help":"Fill only if authority informed","type":"text","label":"If \"Yes\", specify Name of the Authority","options":[],"required":null,"pdf_field":""},{"help":"Authority contact person","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Reference number if any","type":"text","label":"Authority reference no.","options":[],"required":null,"pdf_field":""},{"help":"Authority address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Authority address","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Authority city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Authority state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Authority postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Authority phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Authority mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Authority email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. DETAILS OF OTHER INSURANCE","fields":[{"help":"Name of other insurer if any","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"City of other insurer","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other insurer","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Phone number of other insurer","type":"text","label":"No","options":[],"required":null,"pdf_field":""},{"help":"Phone number of other insurer","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF CONSEQUENTIAL LOSS","fields":[{"help":"","type":"choice","label":"Whether any alteration has been made in the nature of business / occupation of premises after inception of Policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of alteration if any","type":"text","label":"If “Yes”, please give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Were the premises occupied at the time of loss","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date from which premises were unoccupied","type":"date","label":"If no, un-occupied since","options":[],"required":null,"pdf_field":""},{"help":"Reason for un-occupancy","type":"text","label":"for reasons","options":[],"required":null,"pdf_field":""},{"help":"Provide details below","type":"text","label":"Details of Material Damage under Fire & Special Perils Policy / MBD Policy","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer for material damage","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Insurer address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Insurer address","type":"text","label":"Address line 2","options":[],"required":null,"pdf_field":""},{"help":"Insurer city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Insurer postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Insurer state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Insurer phone number","type":"phone","label":"Phone no.","options":[],"required":null,"pdf_field":""},{"help":"Policy number of material damage insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"From and to dates of insurance period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Sum insured for building","type":"amount","label":"Sum Insured : (a) Building","options":[],"required":null,"pdf_field":""},{"help":"Sum insured for Plant & Machinery","type":"amount","label":"(b) P&M","options":[],"required":null,"pdf_field":""},{"help":"Sum insured for Furniture, Fixtures & Fittings","type":"amount","label":"(c) FFF","options":[],"required":null,"pdf_field":""},{"help":"Sum insured for stocks","type":"amount","label":"(d) Stocks","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"At the time of loss, the premises were occupied as :","options":["Manufacturing facility","Warehouse","Dwelling"],"required":null,"pdf_field":""},{"help":"Loss amount for building","type":"amount","label":"Amount of Material Damage loss :(Rs.) (a) Building","options":[],"required":null,"pdf_field":""},{"help":"Loss amount for Plant & Machinery","type":"amount","label":"(b) P&M","options":[],"required":null,"pdf_field":""},{"help":"Loss amount for Furniture, Fixtures & Fittings","type":"amount","label":"(c) FFF","options":[],"required":null,"pdf_field":""},{"help":"Loss amount for stocks","type":"amount","label":"(d) Stocks","options":[],"required":null,"pdf_field":""},{"help":"From and to dates of business interruption","type":"text","label":"Period for which the business was interrupted due to fire / MBD","options":[],"required":null,"pdf_field":""},{"help":"Annual turnover in rupees","type":"amount","label":"What was the annual turn-over for the last financial year?","options":[],"required":null,"pdf_field":""},{"help":"Estimated reduction amount in rupees","type":"amount","label":"What is the estimated reduction in turn-over due to interruption?","options":[],"required":null,"pdf_field":""},{"help":"Estimated gross profit loss in rupees","type":"amount","label":"What is the estimated loss of Gross Profit due to interruption?","options":[],"required":null,"pdf_field":""},{"help":"Expenses incurred to minimize loss","type":"amount","label":"Standing Charges / Expenses incurred for Loss Minimization, if any, Rs.","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Was there any person / organization, in your opinion, responsible for the loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of responsible person/organization","type":"text","label":"If “Yes”, please provide details along with contact numbers and address, if available (this information will be used only for investigation of this claim and source will not be divulged to the suspected party)","options":[],"required":null,"pdf_field":""},{"help":"Describe preventive measures","type":"text","label":"What steps have been taken to prevent recurrence of similar incidence?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. 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 of previous claim","type":"amount","label":"Amount Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. DETAILS OF OTHER INFORMATION","fields":[{"help":"","type":"text","label":"No","options":[],"required":null,"pdf_field":""},{"help":"Other information address","type":"text","label":"Address line 1","options":[],"required":null,"pdf_field":""},{"help":"Other information city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Other information state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Other information phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Other information mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Other information email","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"No","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":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Consequential Loss (Fire) Insurance Policy - retail","attachments":["List of documents as received with this claim form (not detailed in form text)"],"declarations":["Agree to provide additional information if required and guarantee truthfulness of statements.","Understand company may verify identity, address, facts and documents with third parties.","Agree to the company's privacy policy as amended from time to time.","Acknowledge responsibility for timely submission of required documents to avoid delay.","Declare all persons having interest in the property are disclosed and no duplicate claims exist.","Consent 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/1417-consequential-loss-fire-insurance-policy-retail-claim-form"}