{"id":1566,"title":"Employment Practices Liability Insurance Policy 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/Claim_Form_EPL_12b039548c.pdf","sha256":"5b8c4964ae82ddecfd3f448a3d52bd354fd085caf3ef7cadcc3caa7dd97c30f9","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming under the Employment Practices Liability Insurance policy. It is filled by the insured party who is making the claim.","notes":["The insured must not settle or admit liability without insurer's prior written consent.","The intimation is without prejudice and insurer's rights are reserved.","Completion and return of this form should not be delayed if some particulars are not immediately available.","Attach original blank cancelled cheque signed by payee and PAN card copy for EFT payments.","Use the NEFT details from proposal form unless providing new details.","The form includes a declaration that must be signed by the claimant.","The Direct Fund Transfer / EFT mandate form has specific terms and conditions detailed in the form."],"title":"Employment Practices Liability Insurance Policy Claim Form","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"},"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":"Name of the insured party","type":"text","label":"i) Insured Name","options":[],"required":null,"pdf_field":""},{"help":"Full postal address with pin code","type":"text","label":"ii) Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Phone number to contact","type":"phone","label":"iii) Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"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":"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":"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 defendants involved","type":"text","label":"vii) Defendants","options":[],"required":null,"pdf_field":""},{"help":"Explain how you first learned 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 claim amount","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 applies","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":"Type of other insurance cover","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name of insured under other policy","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Policy Period From","options":[],"required":null,"pdf_field":""},{"help":"Indicate if 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 if available","type":"attachment","label":"2. Any legal opinion considered by the Insured","options":[],"required":false,"pdf_field":""},{"help":"Provide lawyer details if appointed","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":false,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"4. Copy of the complete correspondence till date","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Claimant Declaration and Signature","fields":[{"help":"Place 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 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 or No","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 details below if you selected No","type":"text","label":"B) If No, Kindly provide the below mentioned details","options":[],"required":null,"pdf_field":""},{"help":"Name as per bank records","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":"IFSC code of bank branch","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"MICR code if available","type":"text","label":"MICR code of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number of payee","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach original cancelled cheque with signature","type":"attachment","label":"Please attach an Original Blank Cancelled Cheque signed by the payee.","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card copy","type":"attachment","label":"Please attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Employment Practices Liability Insurance 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 endorsements.","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 constitute admission of the claim by the company.","The details provided in the EFT mandate form are final and the company is not responsible for verification.","RTGS/NEFT facility will be effective within 15 days of receipt of mandate form or as reasonably required.","There may be risk of non-payment due to regulatory or other reasons beyond the company's control.","The customer indemnifies the company against any claims or losses arising from RTGS/NEFT transactions.","The company may subcontract obligations under RTGS/NEFT facility.","Customer may terminate RTGS/NEFT facility with 15 days prior written notice to the company.","Termination notice is effective only after company confirmation of receipt.","RTGS/NEFT transactions may attract bank charges borne by the customer.","Company may amend terms and conditions with prior notice where feasible.","Submission of documents or bank details does not imply admission of liability.","Notices may be given by hand, email, website or post to customer's last known address.","Terms and conditions governed by Indian law and disputes subject to Indian courts.","Customer undertakes to refund any excess amount credited in error within 7 days of notification.","Claim payment will be credited after confirmation from company's bankers and continues until revoked."],"dropped_labels":1},"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/1566-employment-practices-liability-insurance-policy-claim-form"}