{"id":1552,"title":"Excess Follow Form for Directors and Officers Liability-Claim Form - UIN (IRDAN152CPLB0549V01202526)","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_D_and_O_Excess_067b4b03bc.pdf","sha256":"95df791a0efed014091f7aa76fd114b17db95f37f42fa09f90496b6655931a0c","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and provide details of a claim under Directors and Officers Liability insurance. The insured fills this form to inform the insurer about the loss or damage and provide necessary information for claim processing.","notes":["The insured must provide information and cooperation as reasonably required by the insurer.","Do not settle or admit liability for any claim without the insurer's prior written consent.","The intimation is without prejudice and does not admit liability.","Completion and return of this form should not be delayed if some particulars are not immediately available.","For EFT payment, attach a signed blank cancelled cheque and PAN card copy of the payee.","Terms and conditions apply for payments through RTGS/NEFT as detailed in the form."],"title":"Excess Follow Form for Directors and Officers Liability-Claim Form - UIN (IRDAN152CPLB0549V01202526)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"Enter your policy number","type":"text","label":"POLICY NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"CLAIM NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured entity","type":"text","label":"i) Insured Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full correspondence address with pin code","type":"text","label":"ii) Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid contact phone number","type":"phone","label":"iii) Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"iv) Period of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Describe the claim in detail","type":"text","label":"i) Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the location where the claim event occurred","type":"text","label":"ii) Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the wrongful act alleged","type":"text","label":"iii) The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Provide the date when the loss occurred","type":"date","label":"iv) Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage alleged","type":"text","label":"v) The nature of the alleged damage","options":[],"required":null,"pdf_field":""},{"help":"List all claimants involved","type":"text","label":"vi) The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List all defendants involved","type":"text","label":"vii) Defendants","options":[],"required":null,"pdf_field":""},{"help":"Explain how the insured was first notified of the claim","type":"text","label":"viii) The manner in which the Insured first became aware of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimated monetary value of the claim","type":"amount","label":"ix) Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Provide a timeline of events related to the claim","type":"text","label":"x) Chronology of events","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Status of Proceedings as on Date","fields":[{"help":"Indicate if other insurance covers this claim","type":"yes-no","label":"Is there any other insurance that may be applicable to this notification? Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify the type of other insurance cover","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"Name of the other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured under other insurance","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of other insurance policy period","type":"text","label":"Policy Period From                                 To","options":[],"required":null,"pdf_field":""},{"help":"Indicate if the other insurer has been notified","type":"yes-no","label":"Has the matter been notified to the Insurer? Yes/No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Attachments to be submitted with Claim Intimation Form","fields":[{"help":"Attach copy of legal notice or written intimation","type":"attachment","label":"1. Copy of the legal notice/ written intimation received by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Attach any legal opinion obtained","type":"attachment","label":"2. Any legal opinion considered by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide details of appointed legal representative if any","type":"text","label":"3. Have you appointed a solicitor or other lawyer to act for you? If so, what is the lawyers name, Firm, address and charge out rates?","options":[],"required":null,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"4. Copy of the complete correspondence till date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","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":"A) 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 in the following bank details if you selected No above","type":"text","label":"B) If No, Kindly provide the below mentioned details","options":[],"required":null,"pdf_field":""},{"help":"Enter payee name exactly as per bank records","type":"text","label":"Payee name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Payee account no","options":[],"required":true,"pdf_field":""},{"help":"Select the type of bank account","type":"choice","label":"Type of account : Saving / Current / Others","options":["Saving","Current","Others"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full bank branch address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code of the bank branch","type":"text","label":"MICR code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of the payee","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach a signed blank cancelled cheque","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the payee. (Mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Attach a copy of the payee's PAN card","type":"attachment","label":"Please attach a PAN Card copy of Payee (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Sign to authorize the bank details","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Directors and Officers Liability claims","attachments":["Copy of the legal notice/ written intimation received by the Insured","Any legal opinion considered by the Insured","Copy of the complete correspondence till date","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 an interest in the property are disclosed as per the proposal or policy endorsement.","No similar claim has been made with any other insurance company except as disclosed.","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 claims.","Receipt of this claim form or documents does not constitute admission of the claim by the company.","The insurer reserves the right to process, reject or require additional information for the claim."],"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/1552-excess-follow-form-for-directors-and-officers-liability-claim-form-uin-irdan152c"}