{"id":1440,"title":"Claim Intimation Form","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/claims/annexure-d-intimation-form.pdf","sha256":"3eac13fc7b17f24dee7eee0c1d81594ed7343f911cd5b20ab138969377352019","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to notify the insurance company about a health insurance claim, either for cashless treatment or reimbursement.","notes":["To be filled in block letters.","Authorized Signatory to sign with date and place.","Use the toll free helpline 1800 200 4030 or email healthserve@universalsompo.com for assistance."],"title":"Claim Intimation Form","submit":{"to":"Health Claims Management: Universal Sompo General Insurance Co Ltd, 1st Floor, Plot No.- C 56 A/13, Sector - 62, Noida, Uttar Pradesh -201309","how":"post / e-mail","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"Write the name of the policy proposer in block letters.","type":"text","label":"a) Proposer Name:","options":[],"required":null,"pdf_field":""},{"help":"Write the name of the patient in block letters.","type":"text","label":"b) Patient Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the health serve card number.","type":"text","label":"c) Universal Sompo Health Serve Card No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the employee number if applicable.","type":"text","label":"d) Employee No:","options":[],"required":null,"pdf_field":""},{"help":"Enter corporate name if applicable.","type":"text","label":"e) Corporate Name (if applicable):","options":[],"required":false,"pdf_field":""},{"help":"Enter a contact phone number.","type":"phone","label":"g) Contact No:","options":[],"required":null,"pdf_field":""},{"help":"Enter a mobile phone number.","type":"phone","label":"h) Mobile No:","options":[],"required":null,"pdf_field":""},{"help":"Enter an email address.","type":"email","label":"i) Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details of the relative attending the patient.","type":"text","label":"j) Contact Details of Attending Relative:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the hospital where treatment is/was taken.","type":"text","label":"a) Hospital Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital's address.","type":"text","label":"b) Hospital Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter the city of the hospital.","type":"text","label":"c) City:","options":[],"required":null,"pdf_field":""},{"help":"Enter the state of the hospital.","type":"text","label":"d) State:","options":[],"required":null,"pdf_field":""},{"help":"Enter the postal pin code of the hospital.","type":"number","label":"e) Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital contact number.","type":"phone","label":"f) Contact No:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital email ID.","type":"email","label":"g) Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of hospital admission (DD/MM/YYYY).","type":"date","label":"h) Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of hospital discharge (DD/MM/YYYY).","type":"date","label":"i) Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Select whether the claim is for cashless treatment or reimbursement.","type":"choice","label":"j) Claim Intimation:","options":["Cashless","Reimbursement"],"required":null,"pdf_field":""},{"help":"Enter the estimated claim amount.","type":"amount","label":"k) Estimated Amount:","options":[],"required":null,"pdf_field":""},{"help":"Describe the ailment or illness.","type":"text","label":"l) Ailment:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Hospitalization Details","fields":[{"help":"Enter the insurance policy number.","type":"text","label":"f) Policy No:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":[],"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/1440-claim-intimation-form"}