{"id":1520,"title":"Extended Warranty Insurance Claim Form","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/KEWI_Claim_form_V_I_22_23_22112022_012004650b.pdf","sha256":"a3f55b848a93a37408dc4278ac76c8ab0059a9aaae5375c7a255e1cdf0b02163","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to notify and claim for loss or damage under the Extended Warranty Insurance policy.","notes":["Attach separate sheet if necessary for additional claim details.","Attach copies of other insurance policies if the asset is insured elsewhere.","Attach an original blank cancelled cheque signed by the payee for EFT mandate.","Attach PAN card copy of the payee for EFT mandate.","The RTGS/NEFT facility will be activated within 15 days of receipt of the mandate form.","The company is not responsible for cross verification of bank details provided.","The claim payment will be credited after confirmation from the company's bankers.","The claimant must sign and date the form."],"title":"Extended Warranty 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":""}],"filled_by":"insured"},{"title":"Loss Details","fields":[{"help":"For company use","type":"text","label":"Claim No:","options":[],"required":false,"pdf_field":""},{"help":"Enter your full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter your full mailing address with pin code","type":"text","label":"Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Enter your phone number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the time and date when the loss occurred","type":"date","label":"Time and Date of Loss (Hrs)","options":[],"required":null,"pdf_field":""},{"help":"Enter the date and time when the loss was discovered","type":"date","label":"Date and Time of Discovery","options":[],"required":null,"pdf_field":""},{"help":"Enter the location where the loss happened","type":"text","label":"Place and address of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the cause or nature of the loss","type":"text","label":"Cause/Reason/ Nature of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the asset involved in the loss","type":"text","label":"Description of Asset","options":[],"required":null,"pdf_field":""},{"help":"Enter the manufacturer of the asset","type":"text","label":"Manufacturer","options":[],"required":null,"pdf_field":""},{"help":"Enter the make, model, and serial number of the asset","type":"text","label":"Make/Model/S. No","options":[],"required":null,"pdf_field":""},{"help":"Enter the purchase date of the asset","type":"date","label":"Date of Purchase of Asset","options":[],"required":null,"pdf_field":""},{"help":"Enter the warranty period provided by the manufacturer","type":"text","label":"Period of Manufacturer’s Warranty","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of the incident causing the loss","type":"text","label":"Detailed description of the incident","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant claim details; attach separate sheet if necessary","type":"text","label":"Additional details related to Claim, if any","options":[],"required":false,"pdf_field":""},{"help":"Provide an estimated monetary value of the loss","type":"amount","label":"Estimated amount of Loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Previous Loss History","fields":[{"help":"Provide details of any previous losses if applicable","type":"text","label":"Previous loss history (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance Details","fields":[{"help":"Provide details of any other insurance policies on the asset; attach copies of such policies","type":"text","label":"Details of other insurance on insured asset (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Claimant Declaration and Signature","fields":[{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the 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":"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":"Enter the payee name exactly as per bank records","type":"text","label":"Payee name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number of the payee","type":"text","label":"Payee account no :","options":[],"required":null,"pdf_field":""},{"help":"Select the type of bank account","type":"choice","label":"Type of account :","options":["Saving","Current","Others"],"required":null,"pdf_field":""},{"help":"Enter the bank's name","type":"text","label":"Name of the bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank branch name","type":"text","label":"Branch Name :","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank branch address","type":"text","label":"Address of the bank:","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"IFSC Code of the bank :","options":[],"required":null,"pdf_field":""},{"help":"Enter the MICR code of the bank branch if available","type":"text","label":"MICR code of the Bank :","options":[],"required":false,"pdf_field":""},{"help":"Enter the PAN number of the payee","type":"text","label":"PAN of the payee:","options":[],"required":true,"pdf_field":""},{"help":"Signature of the bank account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Extended Warranty Insurance claims","attachments":["Separate sheet if necessary for additional claim details","Copies of other insurance policies if applicable","Original Blank Cancelled Cheque signed by the payee","PAN Card copy of Payee"],"declarations":["The statements and 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 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 liability 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/1520-extended-warranty-insurance-claim-form"}