{"id":1418,"title":"COMMERCIAL GENERAL LIABILITY 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/commercial-general-liability-policy-retail/claim-form.pdf","sha256":"3133b095a3f6b049375cf8a6a1f59c76a80f5740aa2617c0d562a9c2104a785a","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to report and claim for an accident or incident under the Commercial General Liability Policy - Retail.","notes":["The issue of this form is not an admission of liability.","Do not delay submission of the form if all particulars are not immediately available; they may be forwarded later.","Attach original documents as required.","This form is for the insured to fill and sign."],"title":"COMMERCIAL GENERAL LIABILITY POLICY- RETAIL CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. Details of the Insured","fields":[{"help":"","type":"text","label":"Insured’s Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Specify whether the claim is made or occurrence based","type":"text","label":"Claims Made/Occurrence Form","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies if applicable","type":"text","label":"Do you have any other insurance policies covering in respect to the same incident? If yes, give details of insurer, policy no., etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Particulars of the Accident","fields":[{"help":"Provide the date and time when the accident occurred","type":"date","label":"Date and time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Specify the location where the accident happened","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Give a detailed description of the accident","type":"text","label":"Describe the accident in detail i.e. how did it occur?","options":[],"required":null,"pdf_field":""},{"help":"State the time and source of first information about the accident","type":"text","label":"When did you first come to know of the accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain what actions were taken immediately after the incident","type":"text","label":"Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Provide contractor details and attach contract agreement copy","type":"text","label":"State name and contractor involved in the incident (if any) and attach a copy of the contract agreement.","options":[],"required":null,"pdf_field":""},{"help":"Provide police report details if applicable","type":"text","label":"Was police report made? If yes, please share details of the report and actions taken by the authority.","options":[],"required":null,"pdf_field":""},{"help":"Date when insurer was first informed about the claim","type":"date","label":"When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Resultant Injuries and Damages - The Injured Persons and Third-Party Property Damage","fields":[{"help":"List injured persons with their details","type":"text","label":"Has any person/s sustained any injuries in the accident? If so, give name/s, address/es and occupation/s of such person/s.","options":[],"required":null,"pdf_field":""},{"help":"Location of injured person during accident","type":"text","label":"State where such person was at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Provide medical treatment details for injured persons","type":"text","label":"Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Provide employment and injury details if injured person is not your employee","type":"text","label":"Was the injured person in your direct employment? If no, please provide the below mentioned details: 1. His employer details. 2. What is the nature of his work? 3. Was he guilty of any insobriety, misconduct or disobedience to instructions or rules? 4. Nature and region of injury?","options":[],"required":null,"pdf_field":""},{"help":"Describe property or livestock damage with owner details","type":"text","label":"Has the accident caused damage to property or livestock? If so, give name/s and address/es of the owner/s of the property and/or the livestock and full description of the property and state the nature of and extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any claims made against you and attach documents if available","type":"text","label":"Has any claim been made upon you by any person/s? If so, state by whom and give full particulars (If claim has been made in writing, attach a copy of the notification received and of the bill, if submitted)","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amount","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with contact details if available","type":"text","label":"Give, if possible, the names, phone numbers and addresses of all witnesses to the accident","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Commercial General Liability Policy - Retail","attachments":["Copy of the contract agreement (if contractor involved)","Copy of police report (if made)","Copy of notification received and bill (if claim made in writing)"],"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 acknowledges receipt of the list of required documents and understands that non-submission may delay claim processing.","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/1418-commercial-general-liability-policy-retail-claim-form"}