{"id":1543,"title":"MONEY SECURE Claim Form NOTIFICATION OF LOSS OR DAMAGE","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/MONEY_SECURE_Claim_Form_ad7af48ae4.pdf","sha256":"738dbdadd396f80b70cb658c8eb282c2d064998c605ce5fe8ef00ed4fed545e2","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming loss or damage under the Money Secure insurance policy. It is filled by the insured person or claimant.","notes":["The issuance or acceptance of this form is not an admission of liability.","Attach documentary proof for the loss description.","Attach copy of FIR if police complaint is lodged.","Attach copy of other insurance policy if loss is covered elsewhere.","Use original blank cancelled cheque signed by payee for bank details.","Attach PAN card copy of payee for bank details.","Signature and stamp of insured/claimant is required.","Date format is DD/MM/YYYY.","Time format is HH/MM.","The form includes an office use only claim number field."],"title":"MONEY SECURE Claim Form NOTIFICATION OF LOSS OR DAMAGE","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":"","type":"phone | email","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Business/ Trade","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"POLICY NO","options":[],"required":null,"pdf_field":""},{"help":"To be entered by insured","type":"text","label":"CLAIM NO","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF LOSS/ ACCIDENT","fields":[{"help":"Date format DD/MM/YYYY; time in HH/MM","type":"date | time","label":"Date and time of accident/ loss/ damage","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place where the loss occurred","options":[],"required":null,"pdf_field":""},{"help":"Name of person at loss location","type":"text","label":"Contact Details of person/s at Loss Location Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Phone number or email of person at loss location","type":"phone | email | text","label":"Contact Details","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss and attach proof documents","type":"text","label":"Please give detailed description as to how the loss occurred & attach the documentary proof for the same","options":[],"required":null,"pdf_field":""},{"help":"Estimated amount of loss in rupees","type":"amount","label":"Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Please specify as to how and when the loss has come to your knowledge","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you suspect any person who might be directly or indirectly privy/party to cause of loss/ act?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of suspected person if any","type":"text","label":"If so, please give the Name, Address, Phone number, employment details etc.","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any Third Party involved or responsible for this reported loss?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of third party if involved","type":"text","label":"If so, please give the Name, Address, Phone number, employment details etc and state the reasons for the same.","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":"Details of witnesses if any","type":"text","label":"If so, please give the Name, Address, Phone number, employment details etc.","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 to authority","type":"text","label":"If 'No', reason for not reporting","options":[],"required":null,"pdf_field":""},{"help":"Select the authority to which loss was reported","type":"choice","label":"If 'Yes', provide details","options":["Fire","Police","Municipality","Other"],"required":null,"pdf_field":""},{"help":"Name of the authority reported to","type":"text","label":"Name of Authority","options":[],"required":null,"pdf_field":""},{"help":"Report or reference number from authority","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":"Contact details of authority","type":"phone | email","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"Date of police complaint and attach FIR copy","type":"date | attachment","label":"Please give details of Date of Police Complaint lodged & attach copy of the FIR","options":[],"required":null,"pdf_field":""},{"help":"Explain delay if any in police reporting","type":"text","label":"If there is any delay in reporting the incident to Police, please give the reasons for the same","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 and attach policy copy","type":"text | attachment","label":"If 'Yes', specify details and attach a copy of the policy","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone | email","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PREVIOUS LOSSES","fields":[{"help":"Provide date, description, value, and insurer for losses in last 3 years","type":"table","label":"Losses during the 3 preceding years Date of Loss, Claim Description and Cause of Loss, Value of Loss (Rs.), Insurer","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":"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"},{"title":"DIRECT FUND TRANSFER / EFT MANDATE FORM","fields":[{"help":"","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":"Fill only if you choose No above","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":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee account no","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of account","options":["Saving","Current","Others"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"MICR code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account 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":""},{"help":"Signature of bank account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["Documentary proof of loss","Copy of FIR","Copy of other insurance policy 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 the proposal or policy endorsement.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and claim rights.","Receipt of this claim form or documents does not constitute admission of claim by the company.","By submitting bank details, the insured agrees to terms and conditions for RTGS/NEFT payments.","The insured agrees to indemnify the company against any claims or losses arising from payment transactions.","The insured may terminate RTGS/NEFT facility with 15 days prior written notice to the company.","The company may amend terms and conditions with prior notice where feasible.","Submission of documents or bank details does not imply admission of liability by the company.","Notices may be given by hand, email, website or post to the customer's last known address.","These terms are governed by Indian law and disputes will be settled in Indian courts.","The insured undertakes to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited upon confirmation from the company's bankers and continues until revoked."],"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/1543-money-secure-claim-form-notification-of-loss-or-damage"}