ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <title>Welcome to Universal Sompo</title> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> <style type="text/css"> <!-- @import url("css/universal.css"); --></style> <script language="javascript" type="text/javascript" src="js/jquery-1.3.2.js"></script> <script language="javascript" type="text/javascript" src="js/popup.js"></script> <script language="javascript" type="text/javascript" src="js/swf.js"></script> <script language="javascript" type="text/javascript" src="js/menu.js"></script> <script src="ajaxmail.js" language="javascript"></script> <script language="javascript" type="text/javascript"> function IsNumeric(sText) { var ValidChars = "0123456789.-"; var IsNumber=true; var Char; for (i = 0; i < sText.length && IsNumber == true; i++) { Char = sText.charAt(i); if (ValidChars.indexOf(Char) == -1) { IsNumber = false; } } return IsNumber; } function check() { var Name=document.form1.Name.value var PhoneNo=document.form1.PhoneNo.value var EmailID=document.form1.EmailID.value var Feedback=document.form1.Feedback.value var reg = new RegExp("^[A-Za-z0-9_-]{1,}[.]?[A-Za-z0-9_-]{1,}@{1}([A-Za-z0-9_-]+[.]{1})+[A-Za-z0-9_-]{1,}$"); if((Name=="") ||!isNaN(Name) || (Name=="Name")) { alert("Please enter your name."); document.form1.Name.focus(); return false; } else if(containsdigit(Name)==true) { alert("Name contains characters."); document.form1.Name.focus(); return false; } else if (Name.charAt(0)==" ") { alert("Name can not start with blank.") document.form1.Name.focus(); return false; } if(PhoneNo=="") { alert("Please enter your contact number."); document.form1.PhoneNo.focus(); return false; } else if(IsNumeric(PhoneNo)==false) { alert("Please enter a numeric value."); document.form1.PhoneNo.focus(); return false; } if(EmailID=="") { alert("Please enter your email id."); document.form1.EmailID.focus(); return false; } else if(!reg.test(EmailID)) { alert("Invalid email id. 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Our claims officials shall soon get in touch with you and shall be happy to help you with the claim procedures. Details of our offices can be found in the USGICL Office locator. </p> <p> Following information needs to be furnished by you while intimating a claim:</p> <ul> <li>Your Contact Numbers</li> <li>Policy Number</li> <li>Name of Insured person,</li> <li>Date & Time of accident,</li> <li>Place of accident,</li> <li>Brief description on incident.</li> <li>Place & contact details of the Insured Person.</li> </ul> <p> <b>Basic document Check list</b></p> <br /> <div id="Div1" style="padding-left: 20px;"> <table class="tableclass"> <tr> <td style="width: 214px" class="tableclass"> List of Documents Death</td> <td style="width: 55px" class="tableclass"> Death Claim</td> <td style="width: 103px" class="tableclass"> Temporary Total Disability(TTD)</td> <td style="width: 120px" class="tableclass"> Permanent Total Disability</td> <td style="width: 109px" class="tableclass"> Permanent Partial Disability</td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Duly filled original Claim Form </td> <td style="width: 55px" class="tableclass" > X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr style="padding-right: 10px;"> <td style="width: 214px" class="tableclass"> Policy copy</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Claim Intimation</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> FIR-Attested or Original</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Death Certificate</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Post Mortem report </td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;"> Inquest/Coroner's Report </td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Final Police Report/Original Panchnama</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Legal Heir certificate /nominee certificate</td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Confirmation of coverage letter </td> <td style="width: 55px" class="tableclass"> X </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Discharge summary of the treating hospital clearly indicating the Hospital Registration No.</td> <td style="width: 55px" class="tableclass"> </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Diagnostic reports <td style="width: 55px" class="tableclass" > </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Leave certificate<td style="width: 55px" class="tableclass"> </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Certificate from government hospital doctor confirming the nature and degree of disability</td> <td style="width: 55px" class="tableclass"> </td> <td style="width: 103px" class="tableclass"> X </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> X </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Termination letter for claim under "Loss of Employment"</td> <td style="width: 55px" class="tableclass"> </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> </td> </tr> <tr> <td style="padding-right: 10px; width: 214px;" class="tableclass"> Photograph of the injured with reflecting disablement <td style="width: 55px" class="tableclass"> </td> <td style="width: 103px" class="tableclass"> </td> <td style="width: 120px" class="tableclass"> X </td> <td style="width: 109px" class="tableclass"> </td> </tr> </table> </div> <br /> *Any other documents as and when requested by the claim settling authority </div> </div> </div> <div id="foooter"> <div id="address_bar" class="address"> <b>Regd & Corp Office :</b> Universal Sompo General Insurance Co Ltd. Unit No 401, 4th Floor,Sangam Complex, 127, <br />Andheri Kurla Road,Andheri (E), Mumbai- 400059. Tel : 022-29211800, Fax : 022-29211844 <br/> <b>Insurance is the subject matter of solicitation. IRDA Registration Number - 134 Control Number -ENG/WBHP/056/25Nov2010</b> <br/> <a href="Privacy Policyindex.html">Privacy Policy</a>| <a href="DisclaimerIndex.html">Disclaimer</a> </div> <script type="text/javascript"> var gaJsHost = (("https:" == document.location.protocol) ? "https://ssl." : "http://www."); document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E")); </script> <script type="text/javascript"> try { var pageTracker = _gat._getTracker("UA-12348426-1"); pageTracker._trackPageview(); } catch(err) {}</script> </div> </div> </div> <!--- pop up window--> <form id="formcontact" name="formcontact"> <div id="popupContactus" style="left: 0px; width: 274px; top: 0px; height: 387px"> <a id="popupContactCloseus" style="font-weight: bold">x</a> <strong> Quick Contact </strong> <hr /> <div id="divcontacttable"> <table style="width:350px;"> <tr> <td class="texttable" style="width:88px"> Contact type</td> <td style="width: 193px"> <select name="ctype" class="formhome" id="ctype" onchange='OnChange(this.form.ctype);'> <option value="Inquiry">Inquiry</option> <option value="Claim">Claim</option> <option value="other">other</option> </select> </td> </tr> <tr> <td class="texttable" style="width:88px"> Name*</td> <td style="width: 193px"><input name="cname" type="text" class="formhome" id="cname" maxlength="50" style="width: 150px" /></td> </tr> <tr> <td class="texttable" style="width:88px"> Emailid*</td> <td style="width: 193px"> <input name="cemailid" type="text" class="formhome" id="cemailid" maxlength="50" style="width: 150px" /></td> </tr> <tr> <td class="texttable" style="width:88px"> Phone Number*</td> <td style="width: 193px" > <input name="cphone" type="text" class="formhome" id="cphone" maxlength="50" style="width: 150px" /></td> </tr> <tr> <td class="texttable" style="width:88px"> </td> <td style="width: 193px"> <span style="font-size: 0.8em; font-family: Tahoma"><em>please enter phone number with your STD code</em></span></td> </tr> <tr> <td class="texttable" style="width: 88px"> </td> <td style="width: 193px"> </td> </tr> <tr> <td class="texttable" style="width: 88px"> Comments*</td> <td style="width: 193px"> &nbsp;<textarea name="ccomment" rows="3" class="formhome" id="ccomment" style="width: 150px"></textarea></td> </tr> <tr ><td colspan="2"> <div id="policynum" style="display:none;"> <table> <tr > <td class="texttable" style="width: 99px"> Policy Number*</td> <td style="width: 196px"> <input name="cpolicyno" type="text" class="formhome" id="cpolicyno" maxlength="50" style="width: 150px" /></td> </tr> </table> </div> </td><td></td></tr> <tr> <td colspan="2"> <div id="productrow"> <table> <tr > <td class="texttable" style="width:78px"> Product</td> <td style="width: 130px"> &nbsp;<select name="Productslist" class="formhome" id="Productslist" style="width: 187px"> <option value="Motor Pvt. Car">Motor Pvt. Car</option> <option value="Individual Health">Individual Health</option> <option value="Fire &amp; Allied Perils">Fire &amp; Allied Perils</option> <option value="Aapat Suraksha">Aapat Suraksha</option> <option value="Householders">Householders</option> <option value="Office Package Policies">Office Package Policies</option> <option value="Farmers&rsquo; Package">Farmers&rsquo; Package</option> <option value="Cattle Policy">Cattle Policy</option> <option value="Others">Others</option> </select></td> </tr></table> </div> </td> <td></td> </tr> <tr> <td class="texttable" style="width: 88px"> </td> <td style="width: 193px"> </td> </tr> <tr> <td class="texttable" style="width: 88px"> </td> <td style="width: 193px"> *<em> required fields</em></td> </tr> </table> <hr /> <div style="float:right;padding-bottom:0px;padding-right:44px;"><input id="Button1" title="Submit" type="button" value="Submit" class="button" onclick="checkNewpop()"; /></div> <table width="100%" border="0" cellpadding="0" cellspacing="0" id="Table1" style="display: none;"> <tr> <td class="formtext"> <span class="style1">We will get in touch with you shortly.</span></td> </tr> </table> </div> </div> </form> <!--- pop up window--> </body> </html>