{"id":1571,"title":"Public Offering of Securities Insurance Claims 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_POSI_a128af5731.pdf","sha256":"9afc4caec3d548369c6dad066f0ad9b3271148024becf6c0b3bf310703730cd8","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming loss or damage under the Public Offering of Securities Insurance policy. It is filled by the insured claimant.","notes":["The insured must not settle or admit liability for any claim without insurer's prior written consent.","The intimation is without prejudice and insurer's rights are reserved.","Do not delay submission of this form if some particulars are not immediately available; forward later.","Attach original blank cancelled cheque signed by payee and PAN card copy for EFT payments.","Use the NEFT details from the 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 terms and conditions apply as stated."],"title":"Public Offering of Securities Insurance Claims 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":"Policy Details","fields":[{"help":"Enter your insurance policy number","type":"text","label":"POLICY NO:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the insured","type":"text","label":"Insured Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address with pin code","type":"text","label":"Address for correspondence including Pin code.","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid contact phone number","type":"phone","label":"Contact Number.","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Details","fields":[{"help":"Describe the claim in detail","type":"text","label":"Description of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Specify the location related to the claim","type":"text","label":"Location of Claim","options":[],"required":null,"pdf_field":""},{"help":"Describe the wrongful act alleged","type":"text","label":"The nature of the alleged Wrongful Act","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the loss occurred","type":"date","label":"Date of Loss","options":[],"required":null,"pdf_field":""},{"help":"Describe the damage alleged","type":"text","label":"The nature of the alleged damage","options":[],"required":null,"pdf_field":""},{"help":"List all claimants involved","type":"text","label":"The names of the claimants","options":[],"required":null,"pdf_field":""},{"help":"List defendants involved in the claim","type":"text","label":"Defendants","options":[],"required":null,"pdf_field":""},{"help":"Explain how you first learned about the claim","type":"text","label":"The manner in which the Insured first became aware of the Claim","options":[],"required":null,"pdf_field":""},{"help":"Provide an estimated monetary value of the claim","type":"amount","label":"Estimated amount of claim","options":[],"required":null,"pdf_field":""},{"help":"Provide a timeline of events related to the claim","type":"text","label":"Chronology of events","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Status of Proceedings as on Date","fields":[{"help":"Indicate if other insurance covers this claim","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":"Specify the type of other insurance cover","type":"text","label":"Type of Cover","options":[],"required":null,"pdf_field":""},{"help":"Name the other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Name the insured under the other policy","type":"text","label":"Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter the start and end dates of the other policy","type":"text","label":"Policy Period From To","options":[],"required":null,"pdf_field":""},{"help":"Indicate if the 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":"Copy of the legal notice/ written intimation received by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Attach any legal opinion obtained","type":"attachment","label":"Any legal opinion considered by the Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide details of appointed legal representative if any","type":"text","label":"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":null,"pdf_field":""},{"help":"Attach all correspondence related to the claim","type":"attachment","label":"Copy of the complete correspondence till date","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claimant 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":"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":"Enter payee name as per bank records","type":"text","label":"Payee name (as per bank records)","options":[],"required":null,"pdf_field":""},{"help":"Enter payee 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 of the bank branch","type":"text","label":"IFSC Code of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code of the bank branch","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":""},{"help":"Attach a signed blank cancelled cheque","type":"attachment","label":"Attach an Original Blank Cancelled Cheque signed by the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach a copy of payee's PAN card","type":"attachment","label":"Attach a PAN Card copy of Payee","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Public Offering of Securities 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 information given 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 with any other insurance company except as disclosed.","No material information relevant to the claim has been withheld or concealed.","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 liability by the insurer.","The details provided in the EFT mandate form are final and the insurer is not responsible for verification.","RTGS/NEFT facility will be effective within 15 days of receipt of mandate form.","The customer indemnifies the insurer against any claims or losses arising from RTGS/NEFT transactions.","The customer may terminate RTGS/NEFT facility with 15 days prior written notice to the insurer.","Termination notice is effective only upon confirmation by the insurer.","RTGS/NEFT transactions may attract bank charges borne by the customer.","The insurer 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 the customer's last address.","Terms and conditions governed by laws of India 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 upon confirmation from insurer's bankers and continues until revoked."],"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/1571-public-offering-of-securities-insurance-claims-form-notification-of-loss-or-dama"}