{"id":1537,"title":"CONSEQUENTIAL LOSS (FIRE) 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/CONSEQUENTIAL_LOSS_FIRE_INSURANCE_Claim_Form_e1b15fa484.pdf","sha256":"dc820455abc6f653ff9a14b06acd15b1a8f3d12a721d7d2171b8ede6af784241","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for consequential loss due to fire. The policyholder or claimant fills it.","notes":["Attach original blank cancelled cheque signed by payee and PAN card copy for EFT payment.","The form must be filled by the insured or claimant.","The issuance or acceptance of this form is not an admission of liability.","Use the exact details as per bank records for EFT mandate.","The terms and conditions for RTGS/NEFT payments apply as printed on the form."],"title":"CONSEQUENTIAL LOSS (FIRE) INSURANCE 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","options":[],"required":null,"pdf_field":""},{"help":"Provide phone number and/or email","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation of the Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured :","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Section : Material Damage","options":["Material Damage"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Business Interruption (Fire)","options":["Business Interruption (Fire)"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Business Interruption (Machinery Breakdown)","options":["Business Interruption (Machinery Breakdown)"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF LOSS/ ACCIDENT","fields":[{"help":"Format DD/MM/YYYY and time","type":"date","label":"Date and time of accident/ loss/ damage","options":[],"required":null,"pdf_field":""},{"help":"Full address of loss location","type":"text","label":"Please give the complete address of loss location including the unit number or block number","options":[],"required":null,"pdf_field":""},{"help":"Phone/email of contact person at loss site","type":"text","label":"Contact Details of person/s at Loss Location","options":[],"required":null,"pdf_field":""},{"help":"Explain how loss/damage occurred","type":"text","label":"Describe Cause of Loss/Damage","options":[],"required":null,"pdf_field":""},{"help":"Business or occupation at premises during loss","type":"text","label":"Purpose for which the premises being used at the time of loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether any alteration has been made in the nature of business/occupation of premises after inception of Policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of alterations if answered Yes above","type":"text","label":"If 'Yes', please give details","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Were the premises occupied at the time of loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date since premises unoccupied if applicable","type":"date","label":"If 'No', un-occupied since","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Duration of business interruption","type":"text","label":"(a) Period for which the business has been interrupted","options":[],"required":null,"pdf_field":""},{"help":"Normal turnover amount","type":"amount","label":"(b) What is the Standard Turn Over","options":[],"required":null,"pdf_field":""},{"help":"Estimated turnover loss","type":"amount","label":"(c) What is the Estimated reduction in turnover","options":[],"required":null,"pdf_field":""},{"help":"Estimated gross profit loss","type":"amount","label":"(d) What is the estimated loss of gross profit","options":[],"required":null,"pdf_field":""},{"help":"Details of any claim under policy extensions","type":"text","label":"(e) Claim under Extensions","options":[],"required":null,"pdf_field":""},{"help":"Actions taken to resume production","type":"text","label":"(f) What are the steps taken towards bring back to production","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"WITNESS DETAILS","fields":[{"help":"","type":"yes-no","label":"Were there any witnesses to the loss/accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Address of witnesses","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone/email of witnesses","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"INFORMATION TO AUTHORITY","fields":[{"help":"","type":"yes-no","label":"Has the loss been reported to an Authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Reason if loss not reported","type":"text","label":"If 'No', reason for not reporting","options":[],"required":null,"pdf_field":""},{"help":"Select authority reported to","type":"choice","label":"If 'Yes', provide details","options":["Fire","Police","Municipalty","Other"],"required":null,"pdf_field":""},{"help":"Name of authority reported to","type":"text","label":"Name of Authority","options":[],"required":null,"pdf_field":""},{"help":"Report or reference number","type":"text","label":"Information Report No/ Authority Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Date of report","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Contact person at authority","type":"text","label":"Contact Person/s","options":[],"required":null,"pdf_field":""},{"help":"Address of authority","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone/email of authority contact","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF OTHER INSURANCE","fields":[{"help":"","type":"yes-no","label":"Is the loss/damage covered under any other Insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other insurance if applicable","type":"text","label":"If 'Yes', specify details and attach a copy of the policy","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Address of other insurer","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone/email of other insurer","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Coverage period of other insurance","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other insurance","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF OTHER INTEREST","fields":[{"help":"","type":"yes-no","label":"Is the Insured the Sole Owner of the property?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details if not sole owner","type":"text","label":"If 'No', specify","options":[],"required":null,"pdf_field":""},{"help":"Type of interest in property","type":"text","label":"Nature of Interest","options":[],"required":null,"pdf_field":""},{"help":"Names of other interested persons","type":"text","label":"Person/s who has/have interest on property","options":[],"required":null,"pdf_field":""},{"help":"Address of other interested persons","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Phone/email of other interested persons","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Columns: Date of Loss, Claim Description and Cause of Loss, Value of Loss (Rs.), Insurer","type":"table","label":"Losses during the 3 preceding years","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF OTHER INFORMATION","fields":[{"help":"","type":"yes-no","label":"Do you wish to provide any other information?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Additional information if any","type":"text","label":"If 'Yes', specify","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":"Fill the following bank details if not continuing with previous NEFT details","type":"section","label":"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 :","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":"Bank IFSC code","type":"text","label":"IFSC Code of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"PAN card number of payee","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach original cancelled cheque signed by payee","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 of payee","type":"attachment","label":"Please attach a PAN Card copy of Payee (mandatory)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION AND SIGNATURE","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign and stamp here","type":"signature","label":"Signature and Stamp of the Insured/ Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Consequential loss claims under fire insurance policies","attachments":["Original Blank Cancelled Cheque signed by the payee","PAN Card copy of Payee","Copy of other insurance policy if applicable"],"declarations":["The information given in this claim form is 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 is withheld or undisclosed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this form or documents does not imply admission of liability by the company.","Claim processing may require further information or may be rejected at company's discretion."],"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/1537-consequential-loss-fire-insurance-claim-form"}