{"id":1514,"title":"Maxima Commercial General 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-commercial-general-liability-insurance-claim-form-zk-v1-24-25-16072024.pdf","sha256":"a67d0947ca5cc38f9c9a978acc9f853a01368d1d777a0aa014a12bc711fc77d5","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 Commercial General Liability Insurance policy.","notes":["Attach copies of notification and bills if claims are made by any person.","Attach details of defective product on separate sheet if applicable.","Attach original blank cancelled cheque signed by payee and PAN card copy for NEFT payment.","This form is not an admission of liability by the insurer.","Use the NEFT details from proposal form unless providing new details."],"title":"Maxima Commercial General 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":null,"pdf_field":""},{"help":"Enter the name of the insured","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full correspondence address with pin code","type":"text","label":"ii) Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident in detail","type":"text","label":"iii) Describe fully how it had occurred?","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"iv) Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the retroactive date if applicable","type":"date","label":"v) Retroactive Date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Enter the indemnity limit as per policy","type":"amount","label":"vi) Limit of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other insurance policies cover this incident and provide details if yes","type":"yes-no","label":"vii) Do you have any other insurance policies covering in respect to the same incident? If yes, give details of insurer, policy no., etc.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the date and time when the accident occurred","type":"date","label":"i) Time and Date of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Enter full address of accident location with pin code","type":"text","label":"ii) Address of the accident site/location with Pin code.","options":[],"required":null,"pdf_field":""},{"help":"State date/time and source of first information about accident","type":"text","label":"iv) When did you first come to know of the accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Describe actions taken immediately after learning of the incident","type":"text","label":"v) Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if defective product caused damage and provide details on separate sheet if yes","type":"yes-no","label":"vi) Is the damage because of a defective product? If yes, please give details of the product features, manufacturing / testing / logistic details / utility, etc. on a separate sheet.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident - The Injured Person","fields":[{"help":"Indicate if anyone was injured","type":"yes-no","label":"a) Has any person sustained any injuries in the accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of injured persons","type":"text","label":"i) Give name/s address/es and occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Describe location of injured person during accident","type":"text","label":"ii) State where such person was at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Indicate if injured persons received medical attention and provide details","type":"yes-no","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":"Provide contact number of injured person or related party","type":"phone","label":"iii) Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Indicate employment status of injured person and employer details if not direct","type":"yes-no","label":"iv) Was the injured person in your direct employment? If No, please provide details of his employer.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the injured person's work nature","type":"text","label":"v) What is the nature of his work?","options":[],"required":null,"pdf_field":""},{"help":"State if injured person was at fault due to misconduct or disobedience","type":"text","label":"vi) Was he guilty of any insobriety, misconduct or disobedience to instructions or rules?","options":[],"required":null,"pdf_field":""},{"help":"Describe type and location of injury","type":"text","label":"vii) Nature and region of injury?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident – Damage to Property of others","fields":[{"help":"Indicate if property or livestock damage occurred","type":"yes-no","label":"b) Has the accident caused damage to property or Livestock?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of owners and description of damaged property/livestock","type":"text","label":"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":[],"required":null,"pdf_field":""},{"help":"Indicate if any claim has been made against you","type":"yes-no","label":"c) Has any claim been made upon you by any person?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of claim and attach copies of notification and bills","type":"text","label":"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":[],"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 addresses","type":"text","label":"e) Give, if possible, the names and address of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if accident was reported to authorities and attach report copy","type":"yes-no","label":"f) Has the accident been reported to any authority? If so, state to whom, attach a copy of the report submitted.","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":""}],"filled_by":"insured"},{"title":"Claimant Declaration and Signature","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Direct Fund Transfer / EFT Mandate Form","fields":[{"help":"Select Yes to use existing NEFT details or No to provide new details","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":null,"pdf_field":""},{"help":"Fill the following bank details if you selected 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 per 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 : Saving Current Others","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 if available","type":"text","label":"• MICR code of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number of payee","type":"text","label":"• PAN of the payee:","options":[],"required":true,"pdf_field":""},{"help":"Attach signed blank 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 to authorize bank details","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Claims under Maxima Commercial General Liability Insurance policies","attachments":["Copy of notification received and bill if claim made by any person","Details of defective product on separate sheet if applicable","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 policy endorsement.","No material information relevant to claim processing has been withheld.","False or fraudulent statements or concealment of material information will void the policy and claim rights.","Receipt of this form or documents does not imply admission of 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/1514-maxima-commercial-general-liability-insurance-claim-form"}