{"id":1437,"title":"PUBLIC LIABILITY ACT INSURANCE POLICY (COMMERCIAL) 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/public-liability-act-insurance-policy/claim-form.pdf","sha256":"7ed59fdfb7eb3191ce919e2489a488f5e763385bef85f5d5a28b70fc12742cea","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under the Public Liability Act Insurance Policy for commercial risks.","notes":["All questions must be answered fully and accurately; use a separate sheet if needed.","Do not dispose of or destroy damaged property without consent of surveyor or insurer.","The form is issued without prejudice to policy terms and is not an admission of liability.","Notify the company without delay once loss or damage is known; send partial information if full details are not available.","The insured should not admit liability or make offers to third parties.","Send any communications received about the accident immediately to the company."],"title":"PUBLIC LIABILITY ACT INSURANCE POLICY (COMMERCIAL) CLAIM FORM","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 location details","type":"text","label":"Where did the accident happen","options":[],"required":true,"pdf_field":""},{"help":"Explain cause of accident clearly","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":"","type":"yes-no","label":"Was the accident reported to Police or any other authority","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide police or 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 any action taken by police or 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":"","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 supporting 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 details of damaged property or livestock","type":"text","label":"Damage caused to property livestock Name & Address of owner","options":[],"required":false,"pdf_field":""},{"help":"Describe damaged property or livestock","type":"text","label":"Description of property/Livestock","options":[],"required":false,"pdf_field":""},{"help":"Describe type of damage","type":"text","label":"Nature of damage","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated damage cost","type":"amount","label":"Estimated cost of damage","options":[],"required":false,"pdf_field":""},{"help":"","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":"Location of injured persons during incident","type":"text","label":"Where was the above person(s) at the time of incident","options":[],"required":false,"pdf_field":""},{"help":"","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","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 Act Insurance Policy (Commercial)","attachments":["Copy of police or authority report if accident reported","Documents indicating any demand made"],"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 acknowledges receipt of 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 duplicate claims have been made.","The insured consents to verification of identity/address/bank details through official registries for KYC purposes.","The insured declares they have not caused the loss by fraud or misrepresentation and believes the declarations to be true."],"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/1437-public-liability-act-insurance-policy-commercial-claim-form"}