{"id":1429,"title":"Claim Form – Public Liability (Industrial & Storage Risks) 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/publiliability-industrial-storage-retail/claim-form.pdf","sha256":"0e47c3d624c4ad3d24a6811266b3a5792425b0c3ee0d326c339e08427442f107","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the insured to report and claim for public liability losses or damages under the Industrial & Storage Risks Insurance Policy (Retail). The policyholder or insured fills it.","notes":["All questions must be answered fully and accurately; use separate sheet if needed.","Do not dispose of damaged property without consent of surveyor/USGI.","Notify the Company without delay once loss or damage is known.","Do not admit liability or make offers to third parties.","Send any communications received about the accident to the Company immediately."],"title":"Claim Form – Public Liability (Industrial & Storage Risks) Insurance Policy (Retail)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the dealership with contact Number and email (office)","options":[],"required":true,"pdf_field":""},{"help":"Provide mobile number and email address","type":"text","label":"Mobile and email","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end date and time of policy period","type":"date","label":"Period of Insurance From __________ (dd/mm/yyyy) __________ (am/pm) to __________ (dd/mm/yyyy) __________","options":[],"required":true,"pdf_field":""},{"help":"Enter limit of indemnity amounts","type":"amount","label":"Limit of Indemnity AOA _____________________ AOY ______________________","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Accident","fields":[{"help":"Enter date and time of accident","type":"date","label":"Date and Time of accident ______________ (mm/dd/yyyy) ____________ (am/pm)","options":[],"required":true,"pdf_field":""},{"help":"Provide exact location of accident","type":"text","label":"Place of accident (exact premises/address)","options":[],"required":true,"pdf_field":""},{"help":"Describe where accident happened","type":"text","label":"Where did the accident happen","options":[],"required":true,"pdf_field":""},{"help":"Explain clearly how accident happened","type":"text","label":"How did the accident occur (state clearly)","options":[],"required":true,"pdf_field":""},{"help":"Date when accident was first reported to insured","type":"date","label":"When was the accident first reported to you","options":[],"required":true,"pdf_field":""},{"help":"Date insured became aware of accident","type":"date","label":"When did you come to know of the accident","options":[],"required":true,"pdf_field":""},{"help":"Indicate if accident was reported to police or authority","type":"yes-no","label":"Was the accident reported to Police or any other authority","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide police/authority report details and attach copy","type":"text","label":"If Yes provide details and attach a copy of the report lodged","options":[],"required":false,"pdf_field":""},{"help":"Describe action taken by authority","type":"text","label":"What was the action taken by authority","options":[],"required":false,"pdf_field":""},{"help":"List names and addresses of witnesses","type":"text","label":"Details of witness Please provide name and address of all witnesses to the incident/accident","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any demand or claim is expected","type":"yes-no","label":"Have you received any indication that a demand or claim will be made upon you for the incident or accident? (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of demand and attach documents","type":"text","label":"If yes, please provide details including who has raised the demand and attach documents indicating the demand made","options":[],"required":false,"pdf_field":""},{"help":"Provide owner name and address of damaged property/livestock","type":"text","label":"Damage caused to property livestock Name & Address of owner","options":[],"required":false,"pdf_field":""},{"help":"Describe the damaged property or livestock","type":"text","label":"Description of property/Livestock","options":[],"required":false,"pdf_field":""},{"help":"Describe nature of damage","type":"text","label":"Nature of damage","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated cost of damage","type":"amount","label":"Estimated cost of damage","options":[],"required":false,"pdf_field":""},{"help":"Indicate if accident caused death or injury","type":"yes-no","label":"Injury to persons Has the accident resulted in death/injuries to any person?  (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of injured persons","type":"text","label":"If yes, provide name, address, age and occupation of person(s) injured","options":[],"required":false,"pdf_field":""},{"help":"State location of injured persons at incident time","type":"text","label":"Where was the above person(s) at the time of incident","options":[],"required":false,"pdf_field":""},{"help":"Indicate if injured persons received medical treatment","type":"yes-no","label":"Whether injured taken to hospital or treated medically (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide medical treatment details","type":"text","label":"If yes, provide details","options":[],"required":false,"pdf_field":""},{"help":"List other insurance policies covering this incident","type":"text","label":"Provide details of other insurances, if any, covering the incident/damage or items/injuries","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any previous losses","type":"text","label":"Details of previous losses, if any","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated claim amount for damages, injuries, etc.","type":"amount","label":"Estimated claim, separately under E, F & G above","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Bank Details (Required for electronic fund transfer)","fields":[{"help":"Provide bank account holder name","type":"text","label":"Name of account holder (as appeared in bank account)","options":[],"required":true,"pdf_field":""},{"help":"Provide bank name and branch","type":"text","label":"Bank Name and branch","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account number","type":"text","label":"Account No","options":[],"required":true,"pdf_field":""},{"help":"Specify account type (e.g. Savings, Current)","type":"text","label":"Account Type","options":[],"required":true,"pdf_field":""},{"help":"Provide MICR code if available","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Provide IFSC code for electronic transfer","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration","fields":[{"help":"Sign the form","type":"signature","label":"Signature of insured","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability (Industrial & Storage Risks) Insurance Policy (Retail)","attachments":["Copy of police or authority report if accident was reported","Documents indicating any demand made","List of documents received with claim form as per declaration"],"declarations":["I/We agree to provide additional information if required and guarantee truthfulness of statements.","I/We understand the Company may verify identity, address, facts and documents with third parties.","I/We have read and agree to the Company's privacy policy as amended from time to time.","I/We have received and understood the list of documents required for claim processing and accept responsibility for delays due to non-submission.","I/We declare all persons having interest in the property are disclosed and no duplicate claims have been made.","I/We consent 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/1429-claim-form-public-liability-industrial-and-storage-risks-insurance-policy-retail"}