{"id":1561,"title":"Private Equity and Venture Capital 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/Claims_Form_PEVC_5bc1714ea7.pdf","sha256":"47ac226ad5bf8eb258b8378e76f0bda9692bbcb4779a95bc6c86e8dbf234aaed","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming loss or damage under the Private Equity and Venture Capital Insurance policy. It is filled by the insured party making the claim.","notes":["Attach original blank cancelled cheque signed by the payee and PAN card copy of payee for NEFT payment.","The RTGS/NEFT facility will be activated within 15 days of receipt of mandate form.","Use block letters to fill the form.","The issuance or acceptance of this form is not an admission of liability.","The form includes sections for office use which should not be filled by the claimant."],"title":"Private Equity and Venture Capital Insurance Claim Form","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 the claim number if available","type":"text","label":"CLAIM NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured","type":"text","label":"i) Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal 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","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 the policy","type":"date","label":"vi) Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the liability limit as per policy","type":"amount","label":"vii) Limit of Liability under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any other insurance covering this 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 the 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":"Describe the wrongful act in detail and timeline","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 liable 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":"State the amount of damages claimed or estimated","type":"amount","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 communications if yes","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 contracts, agreements and communications related to the claim","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 investigation 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 other relevant information and attach 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 the place where 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 here","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":true,"pdf_field":""},{"help":"Fill these details only if you selected No above","type":"section","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":null,"pdf_field":""},{"help":"Enter the 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 the bank's name","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank branch address","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter the MICR code of the bank branch","type":"text","label":"MICR code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter the PAN number of the payee","type":"text","label":"PAN of the payee","options":[],"required":null,"pdf_field":""},{"help":"Sign here to authorize the bank details","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Private Equity and Venture Capital Insurance claims","attachments":["Copy of the court documents if proceedings have commenced","Copies of all communications exchanged with authorities if any action taken","Copy of all relevant contracts and agreements and communications","Copy of internal or external survey, investigation or test reports","Detailed opinion of the Insured’s counsel","Original Blank Cancelled Cheque signed by the payee","PAN Card copy of Payee"],"declarations":["The information provided in this claim form is 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 to any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or concealed.","False or fraudulent statements or suppression of material information will void the policy and claims.","Receipt of this claim form or documents does not constitute admission of liability by the company.","Customer agrees to indemnify Zurich Kotak General Insurance Company for any losses arising from RTGS/NEFT payment issues.","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."],"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/1561-private-equity-and-venture-capital-insurance-claim-form"}