{"id":1555,"title":"Excess Follow Form for Casualty","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Claim_Form_Excess_Follow_Form_Casualty_5591bbf292.pdf","sha256":"4e9d241dbc5a7c6185e23f55ea3b6640437208e7996aac5317ae59a7a40b72e8","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify Zurich Kotak General Insurance Company about a loss or damage claim under a casualty insurance policy.","notes":["Attach original blank cancelled cheque signed by the payee and PAN card copy for EFT mandate.","Claims made by others must be in writing with attached notification and bills.","If damage is due to defective product, provide detailed information on a separate sheet.","The form must be signed and dated by the claimant.","Use clear and complete information to avoid delays."],"title":"Excess Follow Form for Casualty","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"Enter your insurance policy number.","type":"text","label":"POLICY NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter your claim number if available.","type":"text","label":"CLAIM NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured person or entity.","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Enter your 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 phone number to contact you.","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":""},{"help":"Enter the retroactive date if applicable.","type":"date","label":"v) Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the indemnity limit as per your policy.","type":"amount","label":"vi) Limit of Indemnity under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering this incident.","type":"text","label":"vii) Do you have any other insurance policies covering in respect to the same incident? If yes, give details of insurer, policy no., etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Accident","fields":[{"help":"Enter the exact time and date when the accident occurred.","type":"date","label":"i) Time and Date of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"Provide the full address and pin code of the accident location.","type":"text","label":"ii) Address of the accident site/location with pin code.","options":[],"required":null,"pdf_field":""},{"help":"Give a detailed description of how the accident happened.","type":"text","label":"iii) Describe fully how it had occurred?","options":[],"required":null,"pdf_field":""},{"help":"State when and from whom you first learned about the accident.","type":"text","label":"iv) When did you first come to know of the accident and from whom?","options":[],"required":null,"pdf_field":""},{"help":"Explain what actions you took immediately after the incident.","type":"text","label":"v) Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if a defective product caused the damage; provide details separately if yes.","type":"yes-no","label":"vi) Is the damage because of a defective product? If yes, please give details of the product features, manufacturing/ testing/ logistic details/ utility, etc. on a separate sheet.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident - The Injured Person","fields":[{"help":"Indicate if anyone was injured in the accident.","type":"yes-no","label":"a) Has any person sustained any injuries in the accident? If so, Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide full details of injured persons.","type":"text","label":"i) Give name/s address/es and occupation/s of such person/s","options":[],"required":null,"pdf_field":""},{"help":"Describe the location of the injured person during the accident.","type":"text","label":"ii) State where such person was at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Provide details of medical treatment or hospitalisation.","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":"Indicate employment status of injured person and employer details if not employed by you.","type":"yes-no","label":"iv) Was the injured person in your direct employment? If No, please provide details of his employer. Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe the injured person's job or work nature.","type":"text","label":"v) What is the nature of his work?","options":[],"required":null,"pdf_field":""},{"help":"Explain if the injured person was at fault due to misconduct or disobedience.","type":"text","label":"vi) Was he guilty of any insobriety, misconduct or disobedience to instructions or rules?","options":[],"required":null,"pdf_field":""},{"help":"Describe the type and location of injuries sustained.","type":"text","label":"vii) Nature and region of injury?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Consequences of the Accident – Damage to property of others","fields":[{"help":"Indicate if property or livestock was damaged and provide owner details and damage description.","type":"yes-no","label":"b) 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 event of damage. Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"State if any claim was made against you and provide details and attachments if yes.","type":"yes-no","label":"c) Has any claim been made upon you by any person? If so, state by whom and give full particulars (claim should be made in writing; attach a copy of the notification received and of the bill if submitted). Yes/No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts for injuries, property damage, and claims made.","type":"amount","label":"d) Estimated amount of claim separately under (a), (b) and (c).","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with their names and addresses.","type":"text","label":"e) Give, if possible, the names and address of all witnesses to the accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of authority reported to and attach report copy if available.","type":"text","label":"f) Has the accident been reported to any authority? If so, state to whom, attach a copy of the report submitted.","options":[],"required":null,"pdf_field":""},{"help":"Describe any action taken by the authority regarding the accident.","type":"text","label":"c) What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claimant Declaration and Signature","fields":[{"help":"Enter the place where the form is signed.","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing.","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign the form to confirm the declaration.","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 the payee name exactly as per bank records.","type":"text","label":"Payee name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank account number of the payee.","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 the bank's name.","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank branch name.","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Provide the full address of the bank branch.","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch.","type":"text","label":"IFSC Code of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the MICR code of the bank branch.","type":"text","label":"MICR code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the PAN number of the payee.","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Sign to authorize the bank details provided.","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"","attachments":["If damage is due to defective product, details on a separate sheet","Copy of notification received and bill if a claim has been made upon you","Copy of report submitted to authority if accident reported","Original Blank Cancelled Cheque signed by the payee (mandatory)","PAN Card copy of Payee (mandatory)"],"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 material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of 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/1555-excess-follow-form-for-casualty"}