{"id":1573,"title":"CYBER SECURE+ 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/Cyber_Secure_Claim_Form_dac31ac6ce.pdf","sha256":"357b10078bab6b925cf0d1cecce92acd90cff3f6e5f8e44f021eeb7474770273","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders to notify Zurich Kotak General Insurance Company about a loss or damage under the Cyber Secure+ insurance policy and to claim insurance benefits.","notes":["Attach original blank cancelled cheque signed by the payee for NEFT/RTGS payments.","Attach PAN card copy of the payee for fund transfer.","Use documentary proof to support the claim.","Provide timely updates during the incident.","The form is to be filled by the insured or claimant.","The Direct Fund Transfer mandate form details will be activated within 15 days of receipt.","Termination of RTGS/NEFT facility requires 15 days prior written notice to the company at its corporate address."],"title":"CYBER SECURE+ CLAIM FORM Notification of Loss or Damage","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":"To be entered by insured 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 the mailing address","type":"text","label":"ii) Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Provide phone number and/or email address","type":"text","label":"iii) Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"Specify your business or occupation","type":"text","label":"iv) Business/ Trade / Profession/Occupation","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Loss/ Incident","fields":[{"help":"Enter the date when the loss or incident occurred","type":"date","label":"1. Actual Date of loss/ incident Date: DD / MM/ YYYY","options":[],"required":null,"pdf_field":""},{"help":"Select all applicable events that caused the loss","type":"choice","label":"2. Event that resulted into loss","options":["Digital theft of funds","Identity Theft","Data Restoration/ Malware Decontamination","Cyber Bullying/ Stalking/ Loss of reputation","Cyber Extortion","Online Shopping","Online Sales","Social Media/ Media Liability","Network Security Liability","Privacy Breach and Data Breach Liability","Privacy Breach and Data Breach by Third Party","Smart Home Cover","Liability for Intentional Misbehavior of Underage Persons"],"required":null,"pdf_field":""},{"help":"Describe the incident in detail and attach supporting documents","type":"text","label":"3. Please give detailed description as to how the loss occurred & attach the documentary proof for the same","options":[],"required":null,"pdf_field":""},{"help":"Provide the estimated monetary loss in Indian Rupees","type":"amount","label":"4. Estimated Loss (Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Explain when and how you learned about the incident","type":"text","label":"5. Please specify as to how and when the you first became aware of facts or circumstances that might give rise to a loss","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any suspected persons involved","type":"text","label":"6. Do you suspect any person who might be directly or indirectly privy/party to cause of loss/ act? If so, please give the Name, Address, Phone number, etc.","options":[],"required":null,"pdf_field":""},{"help":"Provide ongoing updates about the incident as it develops","type":"text","label":"7. Please provide the periodic and timely updates concurrent with activity taking place during the covered incident.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any third party involved or responsible","type":"text","label":"8. Is any Third Party involved or responsible for this reported loss? If so, please give the Name, Address, Phone number, employment details etc and state the reasons for the same.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Witness Details","fields":[{"help":"Indicate if there were any witnesses","type":"yes-no","label":"1. Were there any witnesses to the loss/accident?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of witnesses if any","type":"text","label":"2. If so, please give the Name, Address, Phone number, employment details etc.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Information to Authority","fields":[{"help":"Indicate if the incident was reported to any authority","type":"yes-no","label":"1. Has the loss been reported to an Authority? If 'No', reason for not reporting. If 'Yes', provide details","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide the name of the authority","type":"text","label":"2. Name of Authority","options":[],"required":null,"pdf_field":""},{"help":"Provide the address of the authority","type":"text","label":"3. Address","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details of the authority","type":"text","label":"4. Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide the report or reference number and date","type":"text","label":"5. Information Report No/ Authority Reference No. and Date","options":[],"required":null,"pdf_field":""},{"help":"Provide name(s) of contact person(s) at the authority","type":"text","label":"6. Contact Person/s","options":[],"required":null,"pdf_field":""},{"help":"Provide date of complaint and attach FIR copy","type":"text","label":"7. Please give details of Date of Police Complaint lodged & attach copy of the FIR and other documents","options":[],"required":null,"pdf_field":""},{"help":"Explain any delay in reporting to police","type":"text","label":"8. If there is any delay in reporting the incident to Police, please give the reasons for the same","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Other Insurance","fields":[{"help":"Indicate if other insurance covers the loss","type":"yes-no","label":"1. Is the loss covered under any other Insurance? If 'Yes', specify details and attach a copy of the policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name of other insurer if applicable","type":"text","label":"2. Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide address of other insurer","type":"text","label":"3. Address","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details of other insurer","type":"text","label":"4. Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide policy number of other insurance","type":"text","label":"5. Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Provide insurance period of other policy","type":"text","label":"6. Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Provide sum insured under other policy","type":"amount","label":"7. Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Details of Previous Losses","fields":[{"help":"List previous losses with date, description, value, and insurer","type":"table","label":"Losses during the 3 preceding years: Date of Loss, Claim Description and Cause of Loss, Value of Loss (Rs.), Insurer","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"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 and stamp the form","type":"signature","label":"Signature and Stamp of the Insured/ Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"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 only if you selected No above","type":"text","label":"B) If No, Kindly provide the below mentioned details","options":[],"required":null,"pdf_field":""},{"help":"Enter payee name exactly as in 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 account type","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 payee","type":"text","label":"PAN of the payee","options":[],"required":null,"pdf_field":""},{"help":"Sign here to authorize fund transfer","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Cyber Secure+ insurance policy claims","attachments":["Documentary proof of loss","Copy of FIR and other police documents","Copy of other insurance policy if applicable","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 interest in the insured property are disclosed as per the policy.","No material information relevant to the claim has been withheld.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this claim form or documents does not imply admission of liability by the company."],"dropped_labels":3},"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/1573-cyber-secure-claim-form-notification-of-loss-or-damage"}