{"id":1546,"title":"ZURICH KOTAK PUBLIC LIABILITY (ACT) 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/Annexure_7_Claim_Form_PL_Act_c8360e95ea.pdf","sha256":"d3fb7b0c87e82dfd4a8d9a6964993fbfb8a261193ae215fb1310d4df4a448e8e","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim under the Zurich Kotak Public Liability (Act) Insurance policy after an accident causing injury, death, or property damage.","notes":["The issue of this form is not an admission of liability.","Do not delay returning the form if some particulars are not immediately available; they may be forwarded later."],"title":"ZURICH KOTAK PUBLIC LIABILITY (ACT) INSURANCE CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Name of Insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy coverage period","type":"text","label":"Period of the Policy:","options":[],"required":null,"pdf_field":""},{"help":"Specify the indemnity limits as per the policy","type":"text","label":"Limits of Indemnity under the Policy:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Date when the accident happened","type":"date","label":"Date of occurrence :","options":[],"required":null,"pdf_field":""},{"help":"Specify time and select A.M. or P.M.","type":"text","label":"Time:","options":["A.M.","P.M."],"required":null,"pdf_field":""},{"help":"Location where the accident occurred","type":"text","label":"Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description; attach signed annexure if needed","type":"text","label":"Brief description of the kind and history of occurrence (attach separate annexure providing the details duly signed)","options":[],"required":null,"pdf_field":""},{"help":"Date when you first became aware of the accident","type":"date","label":"When did you first come to know of the accident?","options":[],"required":null,"pdf_field":""},{"help":"Date when the accident was reported to you","type":"date","label":"When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Date when the insurer was first notified of the claim","type":"date","label":"When was the claim first notified to the Insurer?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident","fields":[{"help":"List injured persons with their details","type":"text","label":"Has any person sustained any injuries in the accident? If so, (i) Give name/s, address/es and occupation/s of such person/s.:","options":[],"required":null,"pdf_field":""},{"help":"Location of injured persons at time of accident","type":"text","label":"(ii) State where such person/s was/were at the time of accident.:","options":[],"required":null,"pdf_field":""},{"help":"Details of medical treatment or hospital admission","type":"text","label":"(iii) Have the injured persons been removed to hospital or medically attended? If so, give particulars.:","options":[],"required":null,"pdf_field":""},{"help":"Details of deceased persons","type":"text","label":"Has any person died in the accident? If so, (i) Give name/s, address/es, age and occupation/s of such person/s.:","options":[],"required":null,"pdf_field":""},{"help":"Details of property or livestock damage and owners","type":"text","label":"Has the accident caused damage to property or livestock? 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 extent of damage.","options":[],"required":null,"pdf_field":""},{"help":"Details of claims made against you; attach copies if available","type":"text","label":"Has any claim been made upon you by any person? If so, state by whom and give full particulars (if claim has been 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, death, and property damage","type":"amount","label":"Estimated amount of claim separately under (a), (b) and (c)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Information","fields":[{"help":"List witnesses with their contact details","type":"text","label":"Give, if possible, the names and addresses of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Name the authority and attach report copy","type":"text","label":"Has the accident been reported to any authority? If so, state to whom and attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe any official action taken","type":"text","label":"What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance policies covering this risk","type":"text","label":"Give particulars of any other insurance, if any, in respect of the same risk.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Sign here to declare the truth of the statements","type":"signature","label":"Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Public Liability (Act) Insurance claims","attachments":["Separate annexure providing details of the accident, duly signed","Copy of notification and bill if claim has been made in writing","Copy of the report submitted to authority if accident reported"],"declarations":["The insured warrants the truth of the statements to the best of their knowledge and belief.","If any false or fraudulent statement, suppression or concealment is made, the claim shall be forfeited and the policy null and void."],"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/1546-zurich-kotak-public-liability-act-insurance-claim-form"}