{"id":1565,"title":"Zurich Cyber Solutions 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_Cyber_Solutions_adaa8355e2.pdf","sha256":"2db225ffcffbfc0be39b7555fb997aa2f0c31cf97f0a8e07ba1414be5a04c9dc","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify Zurich Kotak General Insurance Company about a cyber breach loss or damage claim under their Zurich Cyber Solutions policy.","notes":["The issuance/acceptance of this form is not an admission of liability.","Attach original blank cancelled cheque signed by payee and PAN card copy for EFT payments.","The RTGS/NEFT facility will be activated within 15 days of receipt of mandate form.","Termination of RTGS/NEFT facility requires 15 days prior written notice to Zurich Kotak General Insurance.","Use block letters and provide complete and accurate information to avoid delays.","The form includes sections for first party and third party loss details related to cyber breach.","The form must be signed and dated by the claimant."],"title":"Zurich Cyber Solutions Claim Form Notification of Loss or Damage","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":"401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063, Maharashtra, India"},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Full postal address with pin code","type":"text","label":"Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Phone number including country/area code if applicable","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"Policy coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retroactively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Maximum coverage amount under the policy","type":"amount","label":"Limit of Liability under the Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide details if other insurance covers this incident","type":"text","label":"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/ Details of Cyber Breach","fields":[{"help":"When the cyber breach occurred","type":"date","label":"Time and Date of Occurrence of Loss","options":[],"required":null,"pdf_field":""},{"help":"Place where the breach occurred","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the wrongful act causing the breach","type":"text","label":"The nature of the alleged wrongful act","options":[],"required":null,"pdf_field":""},{"help":"Describe the damages caused by the breach","type":"text","label":"The nature of the alleged damages.","options":[],"required":null,"pdf_field":""},{"help":"Explain how and when you learned about the breach","type":"text","label":"When and how did you first come to know the event/circumstances?","options":[],"required":null,"pdf_field":""},{"help":"Your view on the cause of the breach","type":"text","label":"In your opinion what is the main cause of breach","options":[],"required":null,"pdf_field":""},{"help":"Explain preventive measures taken","type":"text","label":"Describe in detail, have you taken any steps to prevent a similar breach","options":[],"required":null,"pdf_field":""},{"help":"Actions taken immediately after the breach","type":"text","label":"Describe in detail your immediate actions taken upon receipt of the incident?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if police were informed and if not, explain why","type":"choice","label":"Was the breach reported to the police? Yes/No If No, why?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of any impact assessment done","type":"text","label":"Has the impact of the breach been assessed? If yes, by whom? Please share details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of First Party Loss","fields":[{"help":"Explain your direct losses","type":"text","label":"Describe fully your own loss or damage","options":[],"required":null,"pdf_field":""},{"help":"Approximate monetary value of your loss","type":"amount","label":"Estimated amount of loss","options":[],"required":null,"pdf_field":""},{"help":"Date/time of last backup before breach","type":"date","label":"At what date and time was the last pre-breach back up made by you","options":[],"required":null,"pdf_field":""},{"help":"Indicate if business interruption occurred","type":"choice","label":"Was your business partially or fully interrupted by the cyber breach? Yes/No If Yes, please provide below details:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe how business was interrupted","type":"text","label":"Detailed nature of the interruption","options":[],"required":null,"pdf_field":""},{"help":"Approximate percent of business affected","type":"number","label":"Estimated percentage of business impacted","options":[],"required":null,"pdf_field":""},{"help":"When business interruption began","type":"date","label":"Estimated date & time the interruption started","options":[],"required":null,"pdf_field":""},{"help":"Expected date/time for full business resumption","type":"date","label":"Estimated date & time the business can be fully resumed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Third-Party Loss or Damage","fields":[{"help":"Explain losses suffered by third parties","type":"text","label":"Describe fully the third-party loss or damage","options":[],"required":null,"pdf_field":""},{"help":"List third parties likely affected","type":"text","label":"Details of the third parties most probably impacted by the cyber breach","options":[],"required":null,"pdf_field":""},{"help":"Approximate value of third-party losses","type":"amount","label":"Estimated amount of loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if a claim notice was received","type":"choice","label":"Did you already receive notice of claim? Yes/No If Yes, please provide below details of third party:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of third party claimant","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Address of third party claimant","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Describe your relationship with the claimant","type":"text","label":"Relationship between you and third-party","options":[],"required":null,"pdf_field":""},{"help":"Details of the claim made by third party","type":"text","label":"Details on loss/damage claimed","options":[],"required":null,"pdf_field":""},{"help":"State your view on liability and reasons","type":"text","label":"Your opinion on whether you are liable and reasons","options":[],"required":null,"pdf_field":""},{"help":"Attach written claim notice if available","type":"attachment","label":"Please attach a copy of this notice if received in writing.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form to confirm 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":"Choose Yes to use existing NEFT details or No to provide new details","type":"choice","label":"Would you like to continue with the NEFT details provided in the proposal form for Claim payment? Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name as registered with bank","type":"text","label":"Payee name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee account no","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of account: Saving / Current / Others","options":["Saving","Current","Others"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR code of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number of payee","type":"text","label":"PAN of the payee","options":[],"required":null,"pdf_field":""},{"help":"Sign to authorize bank details","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Zurich Cyber Solutions policy claims related to cyber breach loss or damage","attachments":["Please attach a copy of the notice of claim if received in writing.","Please attach an Original Blank Cancelled Cheque signed by the payee. (Mandatory)","Please attach a 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 similar claim has been made with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or undisclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of this claim form or documents does not imply admission of liability by the company.","The claimant agrees to indemnify Zurich Kotak General Insurance for any losses arising from RTGS/NEFT payment issues.","The claimant agrees to the terms and conditions for payments through RTGS/NEFT as stated.","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/1565-zurich-cyber-solutions-claim-form-notification-of-loss-or-damage"}