{"id":1422,"title":"Claim Form – Product Liability 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/product-liability-insurance-policy-retail/claim-form.pdf","sha256":"7357ac9c6bb72dd0141f7cb8b92f3e3672b59cb1d279047de25bc07b1992511e","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to report and claim under the Product Liability Insurance Policy (Retail). The policyholder or insured person fills it.","notes":["The issue of this form is not an admission of liability.","Do not delay returning the form if some particulars are not immediately available; they may be sent later.","Attach all relevant documents as indicated in the form."],"title":"Claim Form – Product Liability Insurance Policy (Retail)","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":"Provide details if other insurance policies cover this incident","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 date and time when the accident occurred","type":"date","label":"Date and time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location where the accident happened","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Explain the circumstances and cause of the accident","type":"text","label":"Describe the accident in detail i.e. how did it occur?","options":[],"required":null,"pdf_field":""},{"help":"State date/time and source of 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 you did immediately after learning about the accident","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","fields":[{"help":"List injured persons with contact and occupation details","type":"text","label":"Has any person/s sustained any injuries in the accident? If so, give name/s, phone numbers and address/es and occupation/s of such person/s.","options":[],"required":null,"pdf_field":""},{"help":"Location of injured persons 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 moved to the hospital or medically attended? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Details of claims made against you and attach related documents","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 details of other authorities informed and attach report copy","type":"text","label":"Has the accident been reported to any other authority? If yes, state to whom and attach copy of the report submitted","options":[],"required":null,"pdf_field":""},{"help":"Describe any actions taken by authorities","type":"text","label":"What action, if any, has been taken by the authority","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated claim amount","type":"amount","label":"Please give an estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with contact details","type":"text","label":"Please give if possible, the names, phone number, addresses of all witnesses to the accident","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Insured","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Print your name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Product Liability Insurance (Retail)","attachments":["Copy of the contract agreement (if any contractor involved)","Copy of police report (if made)","Copy of notification received and bill (if claim made in writing)","Copy of report submitted to other authority (if applicable)"],"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 understands the company is not responsible for delays due to non-submission of required documents or information.","The insured declares 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/1422-claim-form-product-liability-insurance-policy-retail"}