{"id":1513,"title":"Employees Compensation 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/employees-compensation-insurance-claim-form-zk-v1-24-25-12072024.pdf","sha256":"4bdc97b8c4f9703a512072b215597566d1de3a7296e12914b7c255aa3fc2bdb1","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for notifying the insurance company about a claim related to employee compensation insurance. It is filled by the insured employer or claimant to provide details of the injured person, accident, injury, hospitalisation, court procedures, and wage statements.","notes":["This form is only for intimating the Company about claims or seeking permission to settle; do not settle without prior written permission.","Complete and return this form promptly even if some particulars are not immediately available; they may be forwarded later.","Statement of Wages must be carefully completed as per instructions to avoid delays.","Attach mandatory documents as specified, including cancelled cheque and PAN card copy for fund transfer.","Use block letters and provide full details where required."],"title":"Employees Compensation Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details Of Insured","fields":[{"help":"","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No:","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured","type":"text","label":"I) Name","options":[],"required":null,"pdf_field":""},{"help":"Address to send correspondence","type":"text","label":"ii) Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Phone number or email of insured","type":"text","label":"iii) Contact Number/ Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the Injured Person/Deceased","fields":[{"help":"Name of the injured person","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Date of birth, age and gender of injured person","type":"text","label":"ii) DOB, Age and Gender","options":[],"required":null,"pdf_field":""},{"help":"Address of injured person","type":"text","label":"iii) Residential Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Occupation","fields":[{"help":"Describe the occupation","type":"text","label":"i) What is the occupation in which the injured person is employed?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"ii) Was the injured person engaged in this occupation when the accident occurred?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the actual work at accident time if different","type":"text","label":"iii) If not state fully the nature of the work he was doing at the time of the accident?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Employment","fields":[{"help":"Describe employment nature or department/grade","type":"text","label":"i) Nature of Employment\nIf not applicable, provide Department/Grade","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"ii) Is the injured person in your direct employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select the skill level","type":"choice","label":"Skilled\nUn-Skilled\nSemi-Skilled","options":["Skilled","Un-Skilled","Semi-Skilled"],"required":null,"pdf_field":""},{"help":"Contractor details if not direct employment","type":"text","label":"iii) If not give name and address of Contractor?","options":[],"required":null,"pdf_field":""},{"help":"Date of joining service","type":"date","label":"iv) When did the injured person enter your service?","options":[],"required":null,"pdf_field":""},{"help":"Trade or occupation of insured","type":"text","label":"v) Trade/ Occupation of the Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Accident","fields":[{"help":"Date and time when accident happened","type":"date","label":"i) Date and time of accident","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"ii) Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Short description of accident","type":"text","label":"iii) Give brief description of the accident","options":[],"required":null,"pdf_field":""},{"help":"If no, state details and attach required documents","type":"yes-no","label":"iv) Was the claimant at the time of accident in the course of employment?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Injury","fields":[{"help":"Describe the injury","type":"text","label":"i) Give a brief description of injury?","options":[],"required":null,"pdf_field":""},{"help":"Percentage of disability","type":"number","label":"ii) What is the % of disability, if any?","options":[],"required":null,"pdf_field":""},{"help":"Duration in days of disablement","type":"number","label":"iii) What is the probable period of the disablement?","options":[],"required":null,"pdf_field":""},{"help":"Attach doctor's certificate","type":"attachment","label":"Attach a certificate of doctor confirming disability?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"v) Was the injured person under the influence of alcohol or other intoxicant at the time of the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"vi) Was he guilty of any misconduct or disobedience to orders / rules, due to which incident occurred? If so, please give full particulars.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"vii) Are you satisfied that the injured person has met with a bonafide accident of employment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, please submit police report","type":"yes-no","label":"viii) Was the incident reported to Police","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospital","fields":[{"help":"","type":"yes-no","label":"I) Has the injured person been removed to hospital or medically attended?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Hospital details","type":"text","label":"ii) If yes, give name and address of hospital attending to injured person?","options":[],"required":null,"pdf_field":""},{"help":"Admission date","type":"date","label":"iii) Date of admission in hospital:","options":[],"required":null,"pdf_field":""},{"help":"Discharge date","type":"date","label":"iv) Date of discharge from hospital:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Return to Work Details","fields":[{"help":"","type":"yes-no","label":"i) Whether injured person has returned to work?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of return and number of days absent","type":"date","label":"ii) If yes, then the date of return and no. of days of absence?","options":[],"required":null,"pdf_field":""},{"help":"Number of days absent","type":"number","label":"Days","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Court Procedure","fields":[{"help":"","type":"yes-no","label":"i) Has any case been filed in any court of law / tribunal/ Workmen’s Compensation Commissioner in relation to the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies if yes","type":"yes-no","label":"ii) Have any notices / summons of the court been received by you? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date and time of notice receipt","type":"date","label":"iii) Date and time of receipt of notice/summons from the authorities","options":[],"required":null,"pdf_field":""},{"help":"Time of notice receipt","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Status and next hearing date","type":"text","label":"iv) What is the present status of the proceedings? Also give the next date of hearing.","options":[],"required":null,"pdf_field":""},{"help":"Attach all court documents","type":"attachment","label":"v) Provide copies of all the documents that have been submitted to the Court either by you or the workmen/ claimants, and copies of all the documents received with the notice from the court.","options":[],"required":null,"pdf_field":""},{"help":"Attach court orders if yes","type":"yes-no","label":"vi) Has the court passed any interim or final order? If yes, please provide copies of the same.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide date and copy if yes","type":"yes-no","label":"vii) Has the subject matter of the alleged claim/complaint been earlier reported to the Company by an Incident Reporting Form? If yes, please provide date of Incident Reporting Form, and append copy there of","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of Incident Reporting Form","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Provide comments or submit form","type":"text","label":"viii) If no, kindly submit a duly completed Incident Reporting Form / or set out here the Insured's views/ comments on the alleged incident which has resulted in the alleged claim or compliant arising.","options":[],"required":null,"pdf_field":""},{"help":"Describe proposed response","type":"text","label":"ix) The Insured's proposed response to the alleged claim/complaint?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"x) Does the insured propose to/has already availed of, any legal advise.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide lawyer details and opinion","type":"text","label":"xi) If Yes, details of the lawyer/law firm together with their opinion.","options":[],"required":null,"pdf_field":""},{"help":"Describe proposed evaluation steps","type":"text","label":"xii) If No, the proposed steps by the Insured to evaluate the legal liability risk in the context of its response/proposed response and the facts having bearing on the matter.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Miscellaneous","fields":[{"help":"Provide details of other claims","type":"text","label":"i) Details of claims if any preferred by the affected party / claimant for the same loss from another source.","options":[],"required":null,"pdf_field":""},{"help":"Provide any other supporting evidence","type":"text","label":"ii) Any other evidence in support of claim.","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance if any","type":"text","label":"iii) Give particulars of any other insurance, in respect of the same risk.","options":[],"required":null,"pdf_field":""},{"help":"Witness details","type":"text","label":"iv) Give name and address of witness if any?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Statement of Wages","fields":[{"help":"Month for wage entry","type":"text","label":"Month","options":[],"required":null,"pdf_field":""},{"help":"Wages paid in the month","type":"amount","label":"Wages","options":[],"required":null,"pdf_field":""},{"help":"Bonus or other allowances","type":"amount","label":"Bonus (Value of Free Quarters and Any Other)","options":[],"required":null,"pdf_field":""},{"help":"Total wages including allowances","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Daily wage rate if applicable","type":"amount","label":"(a) For daily wage employee, Please provide daily wage rate: Rs.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(b) Were the above stated wages paid, or fallen due for payment, to the injured person?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"(c) Was the injured person absent from work at any time, during the above stated period, for 14 or more consecutive days? If so, give the following particulars:-","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Direct Fund Transfer / EFT mandate Form","fields":[{"help":"","type":"yes-no","label":"A) Would you like to continue with the NEFT details provided in the proposal form for Claim payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill bank details if not continuing with proposal form NEFT details","type":"text","label":"B) If No, Kindly provide the below mentioned details","options":[],"required":null,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Payee name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee account no","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of account : Saving / Current / Others","options":["Saving","Current","Others"],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"IFSC code","type":"text","label":"IFSC Code of the bank","options":[],"required":true,"pdf_field":""},{"help":"MICR code","type":"text","label":"MICR code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"PAN card number","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the payee. (Mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Please attach a PAN Card copy of Payee (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"claims made under Employees Compensation Insurance policies","attachments":["Certificate of doctor confirming disability","Police report (if incident reported to police)","Copies of court notices/summons","Copies of court documents submitted or received","Copies of court orders (interim or final)","Incident Reporting Form (if previously submitted)","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 interest in the property are disclosed as per proposal or endorsements; no duplicate claims made.","No material information relevant to claim processing has been withheld or undisclosed.","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 claim by the Company; Company may require further information or reject claim."],"dropped_labels":1},"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/1513-employees-compensation-insurance-claim-form"}