{"id":1531,"title":"SHOP SECURE (BHARAT LAGHU UDYAM SURAKSHA) 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/SHOP_SECURE_BHARAT_LAGHU_UDYAM_SURAKSHA_Claim_Form_1bdaa8a822.pdf","sha256":"37d6c79bd8c850ca0848188f4295dfda33b911498934bf8ad76bf5ef0fc04206","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for loss or damage under the Shop Secure insurance policy.","notes":["Attach original blank cancelled cheque signed by the payee (mandatory).","Attach PAN Card copy of payee (mandatory).","If insurance is effected with other companies, attach copies of such policies.","Attach copies of reports if loss is intimated to Fire brigade or Police Authorities.","Use separate sheets if necessary for additional details.","The issuance/acceptance of this form is not an admission of liability."],"title":"SHOP SECURE (BHARAT LAGHU UDYAM SURAKSHA) Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF INSURED","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Mortgagee(s) or other persons having financial interest in the property.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"PARTICULARS/ DETAILS OF CYBER BREACH","fields":[{"help":"Provide exact time and date of loss","type":"date","label":"Time and Date of Loss (Hrs)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the accident site/location with pin code.","options":[],"required":null,"pdf_field":""},{"help":"Attach statement of the person who noticed the loss","type":"text","label":"Who noticed the loss first and when","options":[],"required":null,"pdf_field":""},{"help":"Attach separate sheet if necessary","type":"text","label":"Details of the circumstances leading to the loss and cause","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Nature of Loss","options":["Fire","Burglary","Machinery breakdown","Accident","Others (Pl specify)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Please give the address where the affected items can be inspected","options":[],"required":null,"pdf_field":""},{"help":"Attach separate sheet if necessary","type":"amount","label":"Estimated amount of Loss","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"LOSS INTIMATION","fields":[{"help":"","type":"yes-no","label":"Whether the loss is intimated to Fire brigade","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, attach copy of reports","type":"yes-no","label":"Whether the loss is intimated Police Authorities","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Previous loss history (if any)","fields":[{"help":"","type":"text","label":"Previous loss history (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of other insurance on insured premises (if any)","fields":[{"help":"Attach copies of such policies if applicable","type":"text","label":"Details of other insurance on insured premises (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Act of God peril","fields":[{"help":"","type":"attachment","label":"In case of Act of God peril please attach relevant reports","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Third party responsibility","fields":[{"help":"","type":"text","label":"In your opinion is any third party responsible for loss, if yes then please specify the name and address of that person","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Policy and Claim Number","fields":[{"help":"To be entered by Insured","type":"text","label":"POLICY NO:","options":[],"required":null,"pdf_field":""},{"help":"For Company Use","type":"text","label":"CLAIM NO:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DIRECT FUND TRANSFER / EFT MANDATE FORM","fields":[{"help":"","type":"yes-no","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":"","type":"text","label":"Payee name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Payee account no","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Type of account","options":["Saving","Current","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"Provide IFSC code for electronic transfer","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"MICR code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Attach PAN Card copy of Payee (mandatory)","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"claims under Shop Secure (Bharat Laghu Udyam Suraksha) policy","attachments":["Statement of the person who noticed the loss","Separate sheet for details of circumstances leading to loss (if necessary)","Copy of reports from Fire brigade and Police Authorities (if intimated)","Copies of other insurance policies (if any)","Relevant reports in case of Act of God peril","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 the proposal or policy endorsements.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or suppression 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/1531-shop-secure-bharat-laghu-udyam-suraksha-claim-form"}