{"id":1558,"title":"Technology Professional Indemnity Policy 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/Claim_Form_Tech_PI_5c769e5f0c.pdf","sha256":"d502a6958c864e94501e3fff2989816aff0ba68b7ca135ec08b12fb91176f65d","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify Zurich Kotak General Insurance Company of a claim under the Technology Professional Indemnity Policy.","notes":["Please attach an Original Blank Cancelled Cheque signed by the payee (mandatory).","Please attach a PAN Card copy of the payee (mandatory).","The issuance/acceptance of this form is not to be taken as an Admission of Liability.","Use accurate and complete information to avoid claim rejection.","The RTGS/NEFT facility will be effective within 15 days of receipt of the mandate form.","Notices may be given by hand, email, website, or post to the last known address.","The customer is responsible for any bank charges related to RTGS/NEFT transactions."],"title":"Technology Professional Indemnity Policy Claim Form Notification of Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"Enter your policy number","type":"text","label":"POLICY NO:","options":[],"required":null,"pdf_field":""},{"help":"To be entered by Insured if available","type":"text","label":"CLAIM NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured","type":"text","label":"i) 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 a valid email address","type":"email","label":"iv) Email Id","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"v) Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter the retroactive date of coverage","type":"date","label":"vi) Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy's liability limit","type":"amount","label":"vii) Limit of Liability under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering the same incident","type":"text","label":"viii) 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":"Details of the Claimant","fields":[{"help":"Enter full name and address of claimant","type":"text","label":"i) Full name & address of the claimant or potential claimant. (i.e. the party making the claim or potential claim against the Insured)","options":[],"required":null,"pdf_field":""},{"help":"Describe your relationship with the claimant","type":"text","label":"ii) Insured’s relation with the claimant","options":[],"required":null,"pdf_field":""},{"help":"Provide a detailed description of the claim and allegations","type":"text","label":"iii) Description of the claim including a description of the allegations made by the claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Particulars of Loss","fields":[{"help":"Enter the date and time when claim was first intimated","type":"date","label":"i) Date & Time Date on which intimation of the claim was first made against the Insured by the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when you notified the insurer","type":"date","label":"ii) When was the claim/circumstances first notified to Zurich Kotak General Insurance Company (India) Limited?","options":[],"required":null,"pdf_field":""},{"help":"Provide a chronological detailed description of the wrongful act","type":"text","label":"iii) Detailed description of the act in chronological order, as to how, when and where the wrongful act happened as well as when the Insured became first aware of the wrongful act","options":[],"required":null,"pdf_field":""},{"help":"Indicate if legal proceedings have started and attach court documents if yes","type":"yes-no","label":"iv) Have proceedings commenced? If so, please attach a copy of the court documents to be filed or filed before the court by the parties?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other responsible parties if any","type":"text","label":"v) Details of other persons or entities who may be responsible or liable for the loss or damage being claimed -","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature and estimated amount of damages claimed","type":"text","label":"vi) Nature and Quantum of damages claimed against Insured with supporting or, if the claimant has not quantified its damages, insured’s estimate of the quantum of damages which may be claimed against the insured?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any authority has taken action and attach related communications","type":"yes-no","label":"vii) Has any action has been taken by any authority? If yes, please mention the details of the authority and attach copies of all communications exchanged between the insured and authority?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copies of relevant contracts, agreements and communications","type":"attachment","label":"viii) Copy of all relevant contract(s) and/or agreement(s) and all communications between the parties, (e.g. emails, internal memo(s), letter(s), minute(s) or record(s) of meeting(s) if any?","options":[],"required":null,"pdf_field":""},{"help":"Attach relevant reports and lawyer engagement letters if applicable","type":"attachment","label":"ix) Copy of an internal or external, survey, investigation or test reports and all other relevant reports, including the details of lawyers appointed (if any), and the respective engagement letters;","options":[],"required":null,"pdf_field":""},{"help":"Attach legal opinion from your counsel","type":"attachment","label":"x) Detailed opinion of the Insured’s counsel in connection to the merits and demerits of the case (Please attach the opinion)","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional relevant information with supporting documents","type":"text","label":"xi) Are there additional details about which the insured wish to advice, or which may be of interest to an insurer, so that an insurer will have a better understanding of this matter? If so, please provide details along with supporting documentation.","options":[],"required":false,"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 the following bank details if you selected No above","type":"section","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":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Payee account no","options":[],"required":null,"pdf_field":""},{"help":"Select the type of bank account","type":"choice","label":"Type of account : Saving Current Others","options":["Saving","Current","Others"],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number of the payee","type":"text","label":"PAN of the payee","options":[],"required":null,"pdf_field":""},{"help":"Sign as account holder","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Technology Professional Indemnity Policy claims","attachments":["Copy of the court documents if proceedings have commenced","Copies of all communications exchanged with any authority if action taken","Copy of all relevant contract(s) and/or agreement(s) and communications","Copy of internal or external survey, investigation or test reports and lawyer engagement letters","Detailed opinion of the Insured’s counsel","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 form 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.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not constitute admission of liability by the company.","The customer agrees to indemnify Zurich Kotak General Insurance against any losses arising from RTGS/NEFT transactions.","The customer may terminate RTGS/NEFT facility with 15 days prior written notice to Zurich Kotak General Insurance.","Submission of documents or bank details does not imply admission of liability by the company.","These terms and conditions are governed by the laws of India and disputes shall be settled in Indian courts.","The customer undertakes to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited once Zurich Kotak General Insurance receives confirmation from its bankers."],"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/1558-technology-professional-indemnity-policy-claim-form-notification-of-loss-or-dama"}