{"id":2390,"title":"CLAIM FORM - FARMER'S PACKAGE INSURANCE","purpose":"claim","insurer":{"slug":"united-india-insurance","name":"United India Insurance Company Limited"},"source_pdf":"https://uiic.co.in/web/sites/default/files/Policy-Document/Rural%20%26%20Social%20-%20Farmers%20Package%20Insurance_1.pdf","sha256":"fef7939e956a1f17056045ee7f1a4c4b1d0f6ad049546e0907441116d56e7414","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders to claim insurance under the Farmer's Package Insurance policy for various types of losses or damages related to farming assets and activities.","notes":["Use original bills and documents only.","Attach all relevant reports such as police FIR, fire brigade, meteorological, veterinary certificates as applicable.","For personal accident claims, submit Annexures I & II with medical and hospital reports.","For livestock claims, submit Annexures III & IV with veterinary reports and post-mortem certificates.","For poultry claims, submit Annexure V duly completed and signed.","In case of delay in obtaining any forms, return the claim form first to the office which issued the policy.","Fill the form in block letters where applicable."],"title":"CLAIM FORM - FARMER'S PACKAGE INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insured person","type":"text","label":"a) Name of insured:","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"b) Address:","options":[],"required":true,"pdf_field":""},{"help":"Enter your business or occupation","type":"text","label":"c) Business / Occupation:","options":[],"required":null,"pdf_field":""},{"help":"List other persons with interest in the insured property","type":"text","label":"d) Name of other persons having an Interest in the property:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Insurance","fields":[{"help":"List all policy numbers including those with other companies","type":"text","label":"Policy No.(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured Rs.","options":[],"required":true,"pdf_field":""},{"help":"Policy start date","type":"date","label":"Period From","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section I & II - Fire & Allied Perils (Building & Contents)","fields":[{"help":"Provide exact time and date of the loss or event","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe cause of loss or event","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe the insured item affected","type":"text","label":"c) Item of Policy effected (give description)","options":[],"required":true,"pdf_field":""},{"help":"Provide detailed description of the event","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported to police or authorities","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe any actions taken to reduce loss","type":"text","label":"f) Details of steps taken to minimise losses.","options":[],"required":null,"pdf_field":""},{"help":"Attach relevant official reports","type":"attachment","label":"g) Fire or Meteorological or Police Report be submitted in proof of occurrence of loss / event.","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section III - Burglary and House Breaking","fields":[{"help":"Provide exact time and date","type":"date","label":"1. Time and date of occurrence.","options":[],"required":true,"pdf_field":""},{"help":"Describe burglary details","type":"text","label":"2. Details of the act of burglary noticed and how committed by burglars.","options":[],"required":true,"pdf_field":""},{"help":"List stolen property details","type":"text","label":"3. Particulars of property burgled stolen with details such as","options":[],"required":true,"pdf_field":""},{"help":"Enter amount claimed","type":"amount","label":"4. Net amount claimed","options":[],"required":true,"pdf_field":""},{"help":"Describe storage details","type":"text","label":"5. How and where the burgled property was stored?","options":[],"required":null,"pdf_field":""},{"help":"Indicate occupancy status","type":"yes-no","label":"6. Was the premises occupied at the time of burglary?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if security personnel were present","type":"yes-no","label":"7. Was any Security personnel employed?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach FIR and police report if available","type":"yes-no","label":"8. Was the loss reported to Police? If so, please attach a copy of FIR and final Police Report when made available.","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section IV - TV / VCR / VCP","fields":[{"help":"Describe the item","type":"text","label":"a) Description of the TV /VCR/VCP","options":[],"required":true,"pdf_field":""},{"help":"Enter make and model","type":"text","label":"b) Make / Model","options":[],"required":true,"pdf_field":""},{"help":"Enter year only","type":"date","label":"c) Year of Manufacture","options":[],"required":true,"pdf_field":""},{"help":"Original cost price","type":"amount","label":"d) Cost Price","options":[],"required":true,"pdf_field":""},{"help":"Location of installation","type":"text","label":"e) Situation where the set is installed / used","options":[],"required":null,"pdf_field":""},{"help":"Estimated replacement cost","type":"amount","label":"f) Replacement Cost","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section V - Details of Loss / Event (General)","fields":[{"help":"Exact time and date","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe insured item","type":"text","label":"c) Item of Policy effected (given description)","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach official reports","type":"attachment","label":"f) Fire Brigade / Meteorological / Police Report be submitted in proof of occurrence of loss.","options":[],"required":true,"pdf_field":""},{"help":"Name of repairer if applicable","type":"text","label":"g) Name of Repairer.","options":[],"required":null,"pdf_field":""},{"help":"Attach repair estimate","type":"amount","label":"h) Estimated cost of repairs along with estimate.","options":[],"required":null,"pdf_field":""},{"help":"Enter salvage value if any","type":"amount","label":"i) Salvage value offered.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section VI - Pedal Cycle / Cycle Rickshaw","fields":[{"help":"Enter name and make","type":"text","label":"a) Name and make of the pedal cycle / cycle rickshaw:","options":[],"required":true,"pdf_field":""},{"help":"Year only","type":"date","label":"b) Year of Manufacture:","options":[],"required":true,"pdf_field":""},{"help":"Date and purchase value","type":"date","label":"c) Date of purchase and Value:","options":[],"required":true,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"d) Sum Insured:","options":[],"required":true,"pdf_field":""},{"help":"Number of passengers","type":"number","label":"e) Number of passengers carried:","options":[],"required":null,"pdf_field":""},{"help":"Date and time of accident","type":"date","label":"f) When did the accident happen? (Please state date and exact time)","options":[],"required":true,"pdf_field":""},{"help":"Condition at time of accident","type":"yes-no","label":"g) Was the pedal cycle in proper working condition at that time?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"h) Where did the accident happen?","options":[],"required":true,"pdf_field":""},{"help":"Describe accident and damages","type":"text","label":"i) Give full description of the accident, its cause, the damages suffered by the pedal cycle","options":[],"required":true,"pdf_field":""},{"help":"Attach FIR if reported","type":"yes-no","label":"l) Was the accident reported to Police? If so, attach copy of F.I.R. If not, state reason.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Inspection location","type":"text","label":"m) Where can the pedal cycle / cycle rickshaw be inspected?","options":[],"required":null,"pdf_field":""},{"help":"Repairer details","type":"text","label":"n) Name and address of the Repairer.","options":[],"required":null,"pdf_field":""},{"help":"Repair cost estimate","type":"amount","label":"o) Estimated cost of repairs.","options":[],"required":null,"pdf_field":""},{"help":"Third party injury or damage details","type":"text","label":"p) Particulars of any injury to or damage to property of third party:","options":[],"required":null,"pdf_field":""},{"help":"Third party injured person details","type":"text","label":"i) Name and Address of the Injured person","options":[],"required":null,"pdf_field":""},{"help":"Medical treatment details","type":"text","label":"ii) Name of the doctor or Hospital who has given first aid assistance/treatment.","options":[],"required":null,"pdf_field":""},{"help":"Claim details if any","type":"text","label":"q) Has the Injured person or property owner made any claim on you? If so, give particulars and attach copy of notice.","options":[],"required":null,"pdf_field":""},{"help":"Details of animal loss or injury","type":"text","label":"r) Did the accident cause loss of or injury to Livestock or any other animal or bird? If so, give full details.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section VII - Personal Accident / JPA / GAP","fields":[{"help":"Attach completed Annexures I & II and required certificates","type":"attachment","label":"Please return the claim form (Claimant's statement) and the medical / hospital report form vide Annexures I & II attached herewith duly completed and signed along with death certificate and post-mortem report, if necessary.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section VIII - Bio-Gas Plant / Tiny Sectors / Artisans / Village & Cottage Industry","fields":[{"help":"Exact time and date","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe insured item","type":"text","label":"c) Item of Policy effected (give description)","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Actions taken to reduce loss","type":"text","label":"f) Details of steps taken to minimise losses.","options":[],"required":null,"pdf_field":""},{"help":"Attach official reports","type":"attachment","label":"g) Fire or Meteorological or Police Report be submitted in proof of occurrence of loss / event.","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section IX - Livestock / Cattle / Camel / Horse etc.","fields":[{"help":"Attach completed livestock claim form, Annexures III & IV, post-mortem certificate and ear tag","type":"attachment","label":"Please return the livestock claim form duly completed along with the Veterinarian's report in the forms vide attached hereto, vide Annexures III & IV post-mortem certificate and ear tag.","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section X - Kisan Agricultural Pump Set","fields":[{"help":"Describe pump set","type":"text","label":"a) Description of the Pump set:","options":[],"required":true,"pdf_field":""},{"help":"Make and model","type":"text","label":"b) Make / Model","options":[],"required":true,"pdf_field":""},{"help":"Year only","type":"date","label":"c) Year of Manufacture","options":[],"required":true,"pdf_field":""},{"help":"Suction details","type":"text","label":"d) Suction","options":[],"required":null,"pdf_field":""},{"help":"Horsepower and RPM","type":"text","label":"e) H.P / R.P.M.","options":[],"required":null,"pdf_field":""},{"help":"Electrical ratings","type":"text","label":"f) Amp / Volts","options":[],"required":null,"pdf_field":""},{"help":"Rating details","type":"text","label":"g) Rating","options":[],"required":null,"pdf_field":""},{"help":"Location and survey number","type":"text","label":"h) Situation of the pump set with Survey No.","options":[],"required":null,"pdf_field":""},{"help":"Original cost price","type":"amount","label":"i) Cost Price","options":[],"required":true,"pdf_field":""},{"help":"Replacement cost","type":"amount","label":"Replacement Cost","options":[],"required":null,"pdf_field":""},{"help":"Time and date of loss","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe insured item","type":"text","label":"c) Item of Policy effected (given description)","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe extent of loss","type":"text","label":"f) Extent of Loss (as more particularly described in the Statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"Repairer name","type":"text","label":"g) Name of the Repairer","options":[],"required":null,"pdf_field":""},{"help":"Repair or replacement cost estimate","type":"amount","label":"h) Estimated cost of repair / replacement","options":[],"required":null,"pdf_field":""},{"help":"Salvage value if any","type":"amount","label":"i) Salvage value offered","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section XI - Poultry / Birds Insurance","fields":[{"help":"Attach completed Annexure V","type":"attachment","label":"Please return the attached claim form-cum-veterinary certificate vide Annexure V duly completed and signed.","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section XII - Fidelity Guarantee","fields":[{"help":"Describe circumstances of loss","type":"text","label":"1. Full particulars of circumstances surrounding the loss","options":[],"required":true,"pdf_field":""},{"help":"Details of money lost","type":"text","label":"2. Particulars of loss of money denomination wise and details of cash on hand as per receipts.","options":[],"required":true,"pdf_field":""},{"help":"Describe pledged gold jewelry","type":"text","label":"a) Particulars of pledged gold jewelry","options":[],"required":null,"pdf_field":""},{"help":"Describe article","type":"text","label":"b) Full description of article.","options":[],"required":null,"pdf_field":""},{"help":"Owner of article","type":"text","label":"c) To whom the article belonged","options":[],"required":null,"pdf_field":""},{"help":"Seller or source details","type":"text","label":"d) From whom purchased or received (Name and address)","options":[],"required":null,"pdf_field":""},{"help":"Date of purchase or receipt","type":"date","label":"e) Date purchased or received","options":[],"required":null,"pdf_field":""},{"help":"Weight of article","type":"number","label":"f) Weight","options":[],"required":null,"pdf_field":""},{"help":"Cost of article","type":"amount","label":"g) Cost","options":[],"required":null,"pdf_field":""},{"help":"Depreciation amount","type":"amount","label":"h) Deduction for wear and tear and depreciation.","options":[],"required":null,"pdf_field":""},{"help":"Net claim amount","type":"amount","label":"i) Net amount claimed.","options":[],"required":true,"pdf_field":""},{"help":"Describe safes and key procedures","type":"text","label":"3) Details of Safe or Vaults kept in the premises and keys operation procedure practiced.","options":[],"required":null,"pdf_field":""},{"help":"Details of misappropriation","type":"text","label":"4) In the event of loss due to misappropriation of money or gold by employees / dishonesty of appraiser / Pigmy collectors.","options":[],"required":true,"pdf_field":""},{"help":"Defaulter details","type":"text","label":"a) Name of Defaulter and last known address","options":[],"required":true,"pdf_field":""},{"help":"Date and cause of discovery","type":"date","label":"b) State date of discovery of the irregularities and what led to it.","options":[],"required":true,"pdf_field":""},{"help":"Duration and method of embezzlement","type":"text","label":"c) For how long and in what manner have the embezzlements been carried on and concealed ?","options":[],"required":true,"pdf_field":""},{"help":"Previous irregularities if any","type":"text","label":"d) Has there been any previous irregularity in the Defaulter's accounts ? If so, state nature of same.","options":[],"required":null,"pdf_field":""},{"help":"Extent of loss","type":"amount","label":"e) What is the extent of the loss so far as at present ascertained ?","options":[],"required":true,"pdf_field":""},{"help":"Other securities held","type":"text","label":"f) Do you hold any other security than the above policy in respect of the Defaulter ?","options":[],"required":null,"pdf_field":""},{"help":"Remuneration due to defaulter","type":"amount","label":"g) What salary, commission or other remuneration or allowances is due to him ?","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section XIII - Baggage","fields":[{"help":"Time and date of loss","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe insured item","type":"text","label":"c) Item of Policy effected (given description)","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe extent of loss","type":"text","label":"f) Extent of Loss (as more particularly described in the Statement overleaf)","options":[],"required":null,"pdf_field":""},{"help":"Total baggage count","type":"number","label":"g) Total number of baggage carried at the time of travel.","options":[],"required":null,"pdf_field":""},{"help":"Number of checked baggage","type":"number","label":"h) Number of check in baggage entrusted to carrier.","options":[],"required":null,"pdf_field":""},{"help":"Number of hand baggage","type":"number","label":"i) Number of hand baggage","options":[],"required":null,"pdf_field":""},{"help":"Limit per article","type":"amount","label":"j) Single article limit for the item lost","options":[],"required":null,"pdf_field":""},{"help":"Describe paired or set articles","type":"text","label":"k) Details of articles in pairs or sets.","options":[],"required":null,"pdf_field":""},{"help":"List contents of lost baggage","type":"text","label":"l) Contents of lost baggage with full details.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if claim lodged","type":"yes-no","label":"m) In case the Hotel or Travel carrier is responsible for the loss, have you lodged a monetary claim on them.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Response from hotel or carrier","type":"text","label":"n) The response for the above action.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section XIV - Animal & Cart Insurance","fields":[{"help":"Fill details below","type":"group","label":"A) LOSS OR DAMAGE TO CART / VEHICLE - DETAILS OF LOSS / EVENT","fields":[{"help":"Time and date","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Describe insured item","type":"text","label":"c) Item of Policy effected (give description)","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"d) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"e) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Repair estimate","type":"amount","label":"f) Estimate of repairs to the cart / vehicle.","options":[],"required":null,"pdf_field":""},{"help":"Repairer name","type":"text","label":"g) Name of repairer.","options":[],"required":null,"pdf_field":""}],"options":[],"required":true,"pdf_field":""},{"help":"Fill details below","type":"group","label":"B) INJURY TO ANIMAL","fields":[{"help":"Describe accident and injury","type":"text","label":"a) Was the animal injured due to any accident or event? If so, give full description of the accident / event.","options":[],"required":null,"pdf_field":""},{"help":"Veterinary treatment details","type":"text","label":"b) Was the animal given veterinary treatment? If so, by whom.","options":[],"required":null,"pdf_field":""},{"help":"Describe disablement","type":"text","label":"c) Was the animal disabled due to the said accident? If so, describe the nature of disablement supported by the attending Veterinary Doctor.","options":[],"required":null,"pdf_field":""}],"options":[],"required":null,"pdf_field":""},{"help":"Fill details below","type":"group","label":"C) THIRD PARTY LIABILITY (including Passenger Liability)","fields":[{"help":"Date, time and place","type":"date","label":"a) Date hour and place of accident","options":[],"required":true,"pdf_field":""},{"help":"Cause of accident","type":"text","label":"b) Cause of accident (Full information)","options":[],"required":true,"pdf_field":""},{"help":"Describe injury or damage","type":"text","label":"c) Nature and extent of injury or damage","options":[],"required":true,"pdf_field":""},{"help":"Injured persons details","type":"text","label":"d) Name, address and age of injured person/s","options":[],"required":true,"pdf_field":""},{"help":"Details of injury","type":"text","label":"e) Particulars of accidental bodily injury of the injured","options":[],"required":null,"pdf_field":""},{"help":"Owner details","type":"text","label":"f) Name and address of owner of third party property damaged","options":[],"required":null,"pdf_field":""},{"help":"Indicate if owner is your employee","type":"yes-no","label":"g) Is he / she in your service","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Compensation details","type":"text","label":"h) Details of compensation expected","options":[],"required":null,"pdf_field":""},{"help":"Claim communication details","type":"text","label":"i) Has any communication, verbal or written made to you for any claim from third party? If so, give particulars.","options":[],"required":null,"pdf_field":""},{"help":"Compromise details","type":"text","label":"j) Details of compromise made if any.","options":[],"required":null,"pdf_field":""},{"help":"Report details","type":"text","label":"k) When and by whom was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"l) Has the accident been reported to Policy or Public Authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Witness details","type":"text","label":"m) Name/s and address/es of the witnesses to the accident.","options":[],"required":null,"pdf_field":""}],"options":[],"required":null,"pdf_field":""},{"help":"Fill details below","type":"group","label":"D) PERSONAL ACCIDENT TO DRIVER - DETAILS OF LOSS / EVENT","fields":[{"help":"Time and date","type":"date","label":"a) Time & Date of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"b) Cause of Loss / Event","options":[],"required":true,"pdf_field":""},{"help":"Detailed event description","type":"text","label":"c) Describe in detail the total event giving rise to the claim","options":[],"required":true,"pdf_field":""},{"help":"Indicate if reported","type":"yes-no","label":"d) Has the event / loss been reported to Police or other Authorities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Driver's name and age","type":"text","label":"e) Name of the driver and age.","options":[],"required":true,"pdf_field":""},{"help":"Indicate hospital transfer","type":"yes-no","label":"f) Was the driver removed to hospital immediately after the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital details","type":"text","label":"g) If yes, name and address of the hospital.","options":[],"required":null,"pdf_field":""},{"help":"Describe injury","type":"text","label":"h) Nature of injury suffered by the driver due to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Medical treatment outcome","type":"text","label":"i) Result of the medical treatment i.e. whether the driver was disabled due to the accident and if so, the nature of disablement duly certified by the hospital.","options":[],"required":null,"pdf_field":""},{"help":"Assignee details","type":"text","label":"j) Name and age of the assignee in case of death of the driver.","options":[],"required":null,"pdf_field":""},{"help":"Relationship to driver","type":"text","label":"k) Relationship with the diseased driver.","options":[],"required":null,"pdf_field":""},{"help":"Assignee address","type":"text","label":"l) Full address of the assignee.","options":[],"required":null,"pdf_field":""},{"help":"Attach certificates if applicable","type":"yes-no","label":"m) Have you enclosed death certificate and post-mortem report? 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When was the premium paid?","options":[],"required":true,"pdf_field":""},{"help":"Sign declaration","type":"signature","label":"I / we the above named do hereby to the best of my / our knowledge and belief warrant the truth of the foregoing statement in every respect and affirm that proper treatment and care was given to the birds, I / We agree that if I / We have made or in any further declaration the Company may require in respect of the said accident shall make any false statement or any suppression or concealment, the policy shall be void and all rights to recover thereunder in respect of future accidents shall be forfeited.","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Witness signature and name","type":"signature","label":"Name & Signature of Witness:","options":[],"required":true,"pdf_field":""},{"help":"Insured signature","type":"signature","label":"Signature of Insured.","options":[],"required":true,"pdf_field":""},{"help":"Veterinary certification details","type":"group","label":"VETERINARY CERTIFICATE","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Please return this form duly completed within 14 days of the loss together with the necessary documents stated"],"applies_to":"Farmer's Package Insurance claims including fire, burglary, personal accident, livestock, agricultural equipment, poultry, fidelity guarantee, baggage, animal & cart, and agricultural tractors","attachments":["Fire or Meteorological or Police Report","FIR and final Police Report (if applicable)","Death certificate and post-mortem report (if applicable)","Veterinarian's report and post-mortem certificate and ear tag for livestock claims","Annexures I, II, III, IV, V as applicable","Repair estimates","Veterinary Certificate for poultry claims"],"declarations":["The issue of this form does not constitute admission of liability.","The insurance is based on the principle of indemnity only and subject to Policy terms and conditions.","All claims must be based upon the actual value of the goods at the time of event excluding any value addition whatsoever.","I/We hereby declare that the statement made by us in the claim form are true to the best of our knowledge and belief and that I / We have not withheld any material information which has bearing upon the claim.","I / we the above named do hereby to the best of my / our knowledge and belief warrant the truth of the foregoing statement in every respect and affirm that proper treatment and care was given to the birds.","If any false statement or suppression or concealment is made, the policy shall be void and all rights to recover thereunder in respect of future accidents shall be forfeited."],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"mayfair.claims@mayfairwecare.com","label":"Overseas Mediclaim Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Worldwide - Excluding USA & Canada -","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"mayfairassist@mayfairwecare.com","label":"Overseas Mediclaim Medical Emergency Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"://www.mayfairwecare.com/contact/\nContact Details\nMedical Emergency\nGeneral Queries\nGrievances and Escalations\nEmail ID\nmayfairassist@mayfairwecare.com\nmayfair.claims@mayfairwecare.com\ninfo@mayfairwecare.com[AJ1]\nPolicy pays through below plans:\n1. OMP - Policy : B - Wor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18004190133","label":"Overseas Mediclaim Policy Toll-Free Number (India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"l - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact/\nWebsite\nhttps://w","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18888811701","label":"Overseas Mediclaim Policy Toll-Free Number (United States)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"ss\nTower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Loc","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08083045211","label":"Overseas Mediclaim Policy Toll-Free Number (United Kingdom)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"nowledge Park, 4/1 Bannerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please v","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18885192693","label":"Overseas Mediclaim Policy Toll-Free Number (Canada)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"annerghatta Road, Bangalore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.may","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8003211710","label":"Overseas Mediclaim Policy Toll-Free Number (Singapore)","level":null,"hours":null,"applies_to":"travel","source_url":"https://uiic.co.in/web/product/overseas-travel-insurance/OMP-for-Business-and-Holiday","quote":"lore - 560 029\nToll - Free Number\nUnited States: 18888811701 United Kingdom: 08083045211 Canada: 18885192693 Singapore: 8003211710 India: 18004190133 For Other Country Specific Local Contact Numbers, please visit https://www.mayfairwecare.com/contact","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001236889","label":"General Contact Number","level":null,"hours":null,"applies_to":"all","source_url":"https://uiic.co.in/web/","quote":"Links\nCustomer Portal\nKYC Process\nFacebook\nInstagram\nYoutube\nTwitter\nOffice Locator\nIntermediary Portal\nDigi Locker\ntel:18001236889","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/united-india-insurance/2390-claim-form-farmer-s-package-insurance"}