{"id":1438,"title":"Claim Form - Assure Warranty","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/assure-warranty/claim-form.pdf","sha256":"2bf2b2b2811b6bfe307cec67e905f4873548c0b314bbf9e7bd573c2ad11c0ded","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to file a claim under the Assure Warranty policy for loss or damage to insured equipment.","notes":["If any detail is not readily available, send the form without delay and provide missing particulars later.","The issue of this form is not an admission of liability.","Use original documents as required.","The office-use-only sections are not to be filled by the claimant."],"title":"Claim Form - Assure Warranty","submit":{"to":"Universal Sompo General Insurance Company Limited","how":"","address":"Email: contactclaims@universalsompo.com\nToll free: 1-800-12-4030\nHelpline: 012-26748600"},"purpose":"claim","sections":[{"title":"A. INSURED","fields":[{"help":"","type":"text","label":"Policy to.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim to.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"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 the postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Name of the contact person","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe the cause of the loss or damage","type":"text","label":"Describe cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Estimated amount of loss in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Select the time of loss/damage","type":"choice","label":"AM / PM","options":["AM","PM"],"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":"","type":"text","label":"Address line I","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":"Postal code of other insurer","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Landline number of other insurer","type":"phone","label":"Landline No.","options":[],"required":null,"pdf_field":""},{"help":"Alternate phone number","type":"phone","label":"Phone to.","options":[],"required":null,"pdf_field":""},{"help":"Email of other insurer","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF OTHER INTEREST","fields":[{"help":"","type":"text","label":"Address line I","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":"Postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of other interested party","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Email of other interested party","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF ITEMS AFFECTED","fields":[{"help":"Fill details for each affected item in the columns: Description, Maker Name, Year, Serial No., Sum Insured, Last Maintenance Date, AMC/Warranty Expiry, Repair/Replacement Cost","type":"table","label":"DESCRIPTION OF EQUIPMENT, MAKER NAME, YEAR OF MAKE, SL.NO./MACHINE NO., SUM INSURED RS., DATE OF LAST MAINTENANCE, EXPIRY OF AMC/WARRANTY, COST OF REPAIRS/REPLACEMENT","options":[],"required":null,"pdf_field":""},{"help":"Indicate if previous repairs were done","type":"yes-no","label":"Has the affected equipment undergone any repairs previously?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe previous repairs if any","type":"text","label":"If “Yes”, the nature of such repairs","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF REPAIR","fields":[{"help":"Date when repair was done","type":"date","label":"Date of repair","options":[],"required":null,"pdf_field":""},{"help":"Describe the repair work done","type":"text","label":"Nature of repair","options":[],"required":null,"pdf_field":""},{"help":"List parts affected by the damage or repair","type":"text","label":"Parts affected","options":[],"required":null,"pdf_field":""},{"help":"Cost incurred for the repair","type":"amount","label":"Cost of repair","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. 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 claimed previously","type":"amount","label":"Amount Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"H. DETAILS OF OTHER INFORMATION","fields":[{"help":"Any other relevant information","type":"text","label":"Other Information","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Place where form is signed","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":"Assure Warranty claims","attachments":["List of documents with this claim form as received"],"declarations":["I/We agree to provide additional information if required and guarantee the truthfulness of the 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 at www.universalsompo.com.","I/We have received and understood the list of required documents and acknowledge delays may occur if requirements are not met.","I/We declare all persons with interest in the property are disclosed and no other claim for the same loss has been made elsewhere.","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/1438-claim-form-assure-warranty"}