{"id":1508,"title":"Maxima Public Liability Insurance Claim Form","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://www.zurichkotak.com/docs/documents/commercial/claim-forms/maxima-public-liability-insurance-claim-form-zk-v1-24-25-16072024.pdf","sha256":"ee25f22997701f17b937b04f589731592940e4fd3c4ba9e03a9d92d482dd604c","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for loss or damage under the Maxima Public Liability Insurance policy.","notes":["The issuance/acceptance of this form is not an admission of liability.","Completion and return of this form should not be delayed if some particulars are not immediately available; they may be forwarded later.","Attach original blank cancelled cheque signed by payee and PAN card copy for EFT payments.","Use separate sheets if necessary to describe the accident.","Claims made by any person should be in writing with copies of notification and bills attached."],"title":"Maxima Public Liability Insurance Claim Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":"401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. Maharashtra, India"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"For company use","type":"text","label":"Claim No:","options":[],"required":false,"pdf_field":""},{"help":"Enter the name of the insured","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address with pin code","type":"text","label":"ii) Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid phone number","type":"phone","label":"iii) Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"iv) Period of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Enter the indemnity limit as per policy","type":"text","label":"v) Limit of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time of accident","type":"date","label":"i) Time and Date of Occurrence (Hrs)","options":[],"required":null,"pdf_field":""},{"help":"Enter full address of accident location","type":"text","label":"ii) Address of the accident site/location with pin code.","options":[],"required":null,"pdf_field":""},{"help":"Describe the accident briefly","type":"text","label":"iii) Brief description of the accident (attach separate sheets if necessary)","options":[],"required":null,"pdf_field":""},{"help":"Enter date when accident was first known","type":"date","label":"iv) When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of The Accident","fields":[{"help":"Answer Yes or No; if Yes, provide details of injured persons","type":"text","label":"a) Has any person sustained any injuries in the accident? If so, i) Give name/s address/es and occupation/s of such person/s","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide location of injured persons at time of accident","type":"text","label":"ii) State where such person was at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide hospital or medical details","type":"text","label":"iii) Have the injured persons been removed to hospital or medically attended? If so, give particulars.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide details of damaged property or livestock","type":"text","label":"b) Has the accident caused damage to property or Livestock? If so, give name/s and address/es of the owner/s of the property and or livestock and full description of the property and state the nature of and event of damage.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide claimant details and attach documents","type":"text","label":"Has any claim been made upon you by any person? If so, state by whom and give full particulars (claim should be made in writing; attach a copy of the notification received and of the bill if submitted).","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts for injuries, property damage, and claims made","type":"amount","label":"d) Estimated amount of claim separately under (a), (b) and (c).","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with their names and addresses","type":"text","label":"a) Give, if possible, the names and address of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide authority details and attach report","type":"text","label":"b) Has the accident been reported to any authority? If so, state to whom, attach a copy of the report submitted. (like meteorological report, pollution control report, etc.)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe any action taken by authorities","type":"text","label":"c) What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Describe any steps taken by insured to reduce loss","type":"text","label":"d) What action, if any, has been taken by the Insured to mitigate the loss?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policies covering the same risk","type":"text","label":"e) Give particulars of any other insurance, if any, in respect of the same risks","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Direct Fund Transfer / EFT Mandate Form","fields":[{"help":"Select Yes or No","type":"choice","label":"A) Would you like to continue with the NEFT details provided in the proposal form for Claim payment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if answered No above","type":"section","label":"B) If No, Kindly provide the below mentioned details","options":[],"required":null,"pdf_field":""},{"help":"Enter payee name exactly as in bank records","type":"text","label":"• Payee name (as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"• Payee account no.:","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"• Type of account :","options":["Saving","Current","Others"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"• Name of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"• Branch Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"• Address of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"• IFSC Code of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"• MICR code of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of payee","type":"text","label":"• PAN of the payee:","options":[],"required":true,"pdf_field":""},{"help":"Sign as account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Public Liability Insurance claims","attachments":["Separate sheets if necessary for accident description","Copy of notification received and bill if claim made by any person","Copy of report submitted to authority (e.g. meteorological report, pollution control report)","Original Blank Cancelled Cheque signed by the payee","PAN Card copy of Payee"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed as per the proposal or policy endorsement.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form or documents does not constitute admission of the claim by the company."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Family Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India","label":"Health claims department address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.zurichkotak.com/services/claims","quote":"g address as early as possible, but no later than 30 days from the date of discharge.\nHealth claims department address:\nFamily Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India\nIs there any time period for filing pre and post hospital claims?\nThe pre-hospitalisation claim documents duly complete","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"care@zurichkotak.com","label":"Email Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"in\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is chat only number.\nAccessibility\nZoom in page\nZoom out page\nIncrea","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 2120","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"age claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is cha","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-22-69417220","label":"Toll Number (INDIA And Overseas)","level":null,"hours":"IST 8 am to 8 pm","applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"Download policy\nManage policy\nManage claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be","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/zurich-kotak-general-insurance/1508-maxima-public-liability-insurance-claim-form"}