{"id":2398,"title":"BUSINESS 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/BUSINESS_SECURE_Claim_Form_2_046d117475.pdf","sha256":"4bfe9420022814695cfe219c116dc32d8ce17e82e7a18123fae8c9a8ca199e76","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to notify and claim for loss or damage under the Business Secure insurance policy.","notes":["For Fire and Special Perils, Business Interruption (Fire), Burglary & Housebreaking, Electronic Equipments, Machinery Breakdown, All Risk, Baggage, Signage, Plate Glass, Money, Fidelity Guarantee, Employee Compensation, Public Liability, Personal Accident; a supplementary form has to be filled in.","Attach all relevant supporting documents as specified in each section.","Attach original blank cancelled cheque and PAN card copy for direct fund transfer mandate.","Use block letters where applicable.","The issuance/acceptance of this form is not to be taken as an Admission of Liability."],"title":"BUSINESS SECURE Claim Form Notification of Loss or Damage","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details Of Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for correspondence","options":[],"required":null,"pdf_field":""},{"help":"Provide phone number and/or email address","type":"text","label":"Contact Number/ Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Specify applicable insurance sections","type":"text","label":"Please state the sections under which you are making a claim","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Loss/ Damage","fields":[{"help":"Describe location of risk","type":"text","label":"Situation of risk where accident/loss/damage occurred","options":[],"required":null,"pdf_field":""},{"help":"Full address of loss location","type":"text","label":"Please give the complete address including the unit number or block number","options":[],"required":null,"pdf_field":""},{"help":"Provide date and time of incident","type":"date","label":"Date and time of accident/ loss/ damage/ Incident","options":[],"required":null,"pdf_field":""},{"help":"Name of police station notified","type":"text","label":"In the event of loss caused by Burglary, Theft, Fire, Fidelity Guarantee, Liability, GPA which police station has been notified?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Fire And Special Perils, Business Interruption (Fire), Burglary & Housebreaking, Electronic Equipments, Machinery Breakdown, All Risk Insurance Sections","fields":[{"help":"Describe main cause of loss","type":"text","label":"Cause of Accident –Please state the Primary Cause of loss","options":[],"required":null,"pdf_field":""},{"help":"Describe accident circumstances; attach sketch if possible","type":"text","label":"Brief circumstances of accident- (with sketch)","options":[],"required":null,"pdf_field":""},{"help":"Explain how loss happened","type":"text","label":"Please give the full description as to how the loss occurred","options":[],"required":null,"pdf_field":""},{"help":"List witnesses with addresses","type":"text","label":"Names and addresses of witnesses to the accident","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details of witnesses","type":"text","label":"Also, please give their mobile number and mail ids.","options":[],"required":null,"pdf_field":""},{"help":"Attach detailed list of damaged items with make and model","type":"attachment","label":"Details of items destroyed /damaged. Attach a list of items with nature of damages. Also give, make & model of these equipments","options":[],"required":null,"pdf_field":""},{"help":"Attach repair and replacement estimates","type":"attachment","label":"Estimates of repairs and replacements (item-wise). Attach a detailed schedule","options":[],"required":null,"pdf_field":""},{"help":"Provide details of repairers or suppliers","type":"text","label":"Particulars/Details of component repairers / suppliers (Name, Address, Phone number etc.)","options":[],"required":null,"pdf_field":""},{"help":"Provide serial number from policy schedule","type":"text","label":"Serial No. of property as per Schedule attached to Policy","options":[],"required":null,"pdf_field":""},{"help":"Provide supplier name and supply date","type":"text","label":"Name of original supplier for machinery, spares etc. damaged and date of supply.","options":[],"required":null,"pdf_field":""},{"help":"Provide replacement cost","type":"amount","label":"Cost of replacement of the item of the same kind, size and capacity","options":[],"required":null,"pdf_field":""},{"help":"Select whether item was new or used","type":"choice","label":"Was the damaged item new or second hand?","options":["new","second hand"],"required":null,"pdf_field":""},{"help":"Provide sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide property location","type":"text","label":"Location of the Property","options":[],"required":null,"pdf_field":""},{"help":"Indicate if business interruption is expected","type":"yes-no","label":"Is there any business interruption anticipated? If so please fill in the FLOP claim form as a supplementary form","options":["yes","no"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Details for Fire and Special Perils etc.","fields":[{"help":"Provide last maintenance date","type":"date","label":"Date (before this accident) when the machines was last overhauled / attended for maintenance","options":[],"required":null,"pdf_field":""},{"help":"Provide warranty details if applicable","type":"text","label":"Is there any warranty / guarantee from manufacturer / supplier covering the present loss/damage? If so, details","options":[],"required":null,"pdf_field":""},{"help":"List past incidents in last 3 years","type":"text","label":"Details of accidents/loss/damage during the past 3 years (whether claim preferred or not)","options":[],"required":null,"pdf_field":""},{"help":"Provide other insurance details if any","type":"text","label":"Is the property insured under any other Policy with any other insurer? If so, details","options":[],"required":null,"pdf_field":""},{"help":"Provide details of compensation from other insurers","type":"text","label":"Are you getting compensation in respect of the present loss / damage from any other insurance? If so, details.","options":[],"required":null,"pdf_field":""},{"help":"Describe consequential losses or liabilities","type":"text","label":"Details of consequential loss / liability, if any, on account of this accident.","options":[],"required":null,"pdf_field":""},{"help":"Provide repairer details if repairs started","type":"text","label":"Have the repair been put in hand? If so give name and address of repairs.","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated repair cost and duration","type":"text","label":"Indicate the estimated repair charges and repair time.","options":[],"required":null,"pdf_field":""},{"help":"Provide salvage value if any","type":"amount","label":"State salvage value of the damage item.","options":[],"required":null,"pdf_field":""},{"help":"Provide location for inspection","type":"text","label":"Where can the damaged items to be inspected?","options":[],"required":null,"pdf_field":""},{"help":"Provide any other relevant details","type":"text","label":"Any other particular relevant to the damages.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurances covering loss","type":"text","label":"Are there any other insurance affected by you or any other person(s) covering the loss sustained or any part thereof? If so, give details.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Personal Accident Insurance","fields":[{"help":"Name of injured or deceased insured person","type":"text","label":"Name of the insured person who had sustained injury / Died","options":[],"required":null,"pdf_field":""},{"help":"Occupation of the insured person","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Age of the insured person","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of accident","type":"text","label":"Cause of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries","type":"text","label":"Details of injuries sustained","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment received","type":"text","label":"Details of treatment","options":[],"required":null,"pdf_field":""},{"help":"Provide disability information if any","type":"text","label":"Disability Details","options":[],"required":null,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide police report details if available","type":"text","label":"Police Report details, if any","options":[],"required":null,"pdf_field":""},{"help":"Duration of hospital stay","type":"text","label":"Period of stay in hospital for Hospital cash benefit","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Public Liability / Tenant’s Legal Liability","fields":[{"help":"Date and time of incident","type":"date","label":"Date & Time of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of accident","options":[],"required":null,"pdf_field":""},{"help":"Describe accident and history","type":"text","label":"Brief description of the kind and history of the occurrence","options":[],"required":null,"pdf_field":""},{"help":"Date accident was reported","type":"date","label":"When was the accident reported to you?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if injuries occurred","type":"yes-no","label":"Has any person sustained any injuries in the accident?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Occupation of injured person(s)","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Location of injured person(s) at accident time","type":"text","label":"State where such person(s) was/were at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Names of injured persons","type":"text","label":"If so, Give name(s) of such Person(s)","options":[],"required":null,"pdf_field":""},{"help":"Addresses of injured persons","type":"text","label":"Address(es)","options":[],"required":null,"pdf_field":""},{"help":"City of injured persons","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Pin code of injured persons","type":"text","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if medical attention was given","type":"yes-no","label":"Has/Have the injured person(s) been removed to hospital or medically attended?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Details of medical treatment","type":"text","label":"If so, give particulars","options":[],"required":null,"pdf_field":""},{"help":"Indicate if property or livestock damaged","type":"yes-no","label":"Has the accident/Loss caused damage to property or livestock?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Indicate if claim made against you","type":"yes-no","label":"Has any claim been made upon you by any person?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Provide estimated claim amounts","type":"amount","label":"Estimated amount of Claim separately under each section","options":[],"required":null,"pdf_field":""},{"help":"Indicate if reported to authority","type":"yes-no","label":"Has the accident been reported to any authority?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Provide authority name and attach report copy","type":"text","label":"If so, state to whom and attach a copy of the report submitted","options":[],"required":null,"pdf_field":""},{"help":"Describe authority action","type":"text","label":"What action, if any, has been taken by the authority?","options":[],"required":null,"pdf_field":""},{"help":"Provide relevant legal statute details","type":"text","label":"Give details of Statute/Law under which in your opinion, liability may arise","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Fidelity Guarantee","fields":[{"help":"Name of employee at fault","type":"text","label":"Name of the defaulting employee in full","options":[],"required":null,"pdf_field":""},{"help":"Employee's current address","type":"text","label":"His present address","options":[],"required":null,"pdf_field":""},{"help":"Loss amount due to employee","type":"amount","label":"Amount of loss sustained","options":[],"required":null,"pdf_field":""},{"help":"Date loss was discovered","type":"date","label":"Date of discovery","options":[],"required":null,"pdf_field":""},{"help":"Describe how the act was done","type":"text","label":"How exactly was the act committed","options":[],"required":null,"pdf_field":""},{"help":"Employee's role and location","type":"text","label":"In what capacity was the employee working and where?","options":[],"required":null,"pdf_field":""},{"help":"Audit frequency, auditor and last audit date","type":"text","label":"How often were the Account Books/Stock Books at the place of the defaulting employee’s employment audited and by whom? When was the last audit done?","options":[],"required":null,"pdf_field":""},{"help":"Details of any assets held from employee","type":"text","label":"Have you any moneys, estate, or effects of the employee in your possession? If so, give particulars with amounts.","options":[],"required":null,"pdf_field":""},{"help":"Details of securities held","type":"text","label":"Do you hold any other security from the employee? If so, state its nature and amount.","options":[],"required":null,"pdf_field":""},{"help":"Describe actions taken against employee","type":"text","label":"Have you taken any action against the employee? If so, state the nature of action taken.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Baggage","fields":[{"help":"Describe lost or damaged baggage","type":"text","label":"Details of Baggage lost/ damaged","options":[],"required":null,"pdf_field":""},{"help":"Provide value of lost items","type":"amount","label":"Value of the items lost","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Money","fields":[{"help":"Date loss was discovered","type":"date","label":"Date of discovery of loss","options":[],"required":null,"pdf_field":""},{"help":"Route of money transit","type":"text","label":"What were the places between which money was in transit","options":[],"required":null,"pdf_field":""},{"help":"Location of loss","type":"text","label":"Where did the loss occur","options":[],"required":null,"pdf_field":""},{"help":"Person who reported loss","type":"text","label":"By whom was the loss reported","options":[],"required":null,"pdf_field":""},{"help":"Custodian of money during loss","type":"text","label":"In whose custody was the money at the time of loss","options":[],"required":null,"pdf_field":""},{"help":"Names of accompanying persons","type":"text","label":"Who were the other persons accompanying the person carrying the money","options":[],"required":null,"pdf_field":""},{"help":"Indicate if armed guards were present","type":"yes-no","label":"Were armed guards accompanying the money","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Describe circumstances of loss","type":"text","label":"Brief details of the exact circumstances leading to the loss","options":[],"required":null,"pdf_field":""},{"help":"Method of carrying money","type":"text","label":"How was the money carried","options":[],"required":null,"pdf_field":""},{"help":"Transport used for money","type":"text","label":"By what conveyance was the money carried","options":[],"required":null,"pdf_field":""},{"help":"Total money amount carried","type":"amount","label":"What was the total amount of money that was being carried","options":[],"required":null,"pdf_field":""},{"help":"Describe recovery efforts","type":"text","label":"Steps taken to recover lost money","options":[],"required":null,"pdf_field":""},{"help":"Employment start date of involved employees","type":"date","label":"When did the employees concerned enter your service?","options":[],"required":null,"pdf_field":""},{"help":"Indicate prior involvement in loss","type":"yes-no","label":"Was any one of them involved in a similar loss before?","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Provide Fidelity Guarantee coverage details","type":"text","label":"Are any of them covered under any Fidelity Guarantee Policy? If so, give details.","options":[],"required":null,"pdf_field":""},{"help":"Details of cash deposits or securities held","type":"text","label":"Do you hold any cash deposit or any security from them?","options":[],"required":null,"pdf_field":""},{"help":"Attach medical or legal documents if applicable","type":"attachment","label":"Has the money carrying employee been assaulted during burglary or holdup resulting in death / bodily injury / physical separation of a limb or the loss of an eye or causing him to be prevented from engaging in his usual employment? If so, please provide copy of relevant medical papers / disability certificate / post mortem report, as the case maybe.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Plate Glass / Signage","fields":[{"help":"Exact location of sign or glass","type":"text","label":"Address where neon sign / plate glass is situated (Please state the precise position )","options":[],"required":null,"pdf_field":""},{"help":"Dimensions of broken item","type":"text","label":"Size of the plate glass / neon sign broken","options":[],"required":null,"pdf_field":""},{"help":"Explain cause of damage","type":"text","label":"Cause of breakage","options":[],"required":null,"pdf_field":""},{"help":"Describe incident","type":"text","label":"Brief description of occurrence","options":[],"required":null,"pdf_field":""},{"help":"Value of damaged items","type":"amount","label":"Value of items damaged","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Directors And Officers Liability","fields":[{"help":"Describe claim circumstances","type":"text","label":"Brief Description of the Claim Circumstances","options":[],"required":null,"pdf_field":""},{"help":"Date notice of claim received","type":"date","label":"When did you receive the notice of Claim?","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of claim notice","type":"attachment","label":"(Kindly provide the copy of the Notice so received)","options":[],"required":null,"pdf_field":""},{"help":"Provide insured person's details","type":"text","label":"Details of the insured person against whom the Notice is served?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of parties serving notice","type":"text","label":"Details of the party(s) who have served notice on the Insured person? (Kindly Attach separate annexure if the space provided is not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"List claim heads","type":"text","label":"Heads under which the claim is made : (Kindly Attach separate annexure if the space provided is not sufficient)","options":[],"required":null,"pdf_field":""},{"help":"Attach any additional claim information","type":"attachment","label":"Do you wish to provide any additional information with respect to the claim: If yes, please attach the same in annexure","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Employee Compensation","fields":[{"help":"Provide injured person's details","type":"text","label":"Details of the Injured person","options":[],"required":null,"pdf_field":""},{"help":"Name of injured person","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Age and address of injured person","type":"text","label":"Age and address","options":[],"required":null,"pdf_field":""},{"help":"Occupation of injured person","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Describe work nature during accident","type":"text","label":"Nature of work of the injured person at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Indicate if direct employee","type":"yes-no","label":"Was the injured person in your direct employment","options":["yes","no"],"required":null,"pdf_field":""},{"help":"Employment start date","type":"date","label":"When did you enter the service","options":[],"required":null,"pdf_field":""},{"help":"Describe capacity if not direct employee","type":"text","label":"If not in your direct employment","options":[],"required":null,"pdf_field":""},{"help":"Role at accident time","type":"text","label":"In what capacity was he working at the time of accident","options":[],"required":null,"pdf_field":""},{"help":"Hospital 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no","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of account","options":["Saving","Current","Others"],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code of the bank","options":[],"required":true,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR code of the Bank","options":[],"required":true,"pdf_field":""},{"help":"PAN number of payee","type":"text","label":"PAN of the payee","options":[],"required":true,"pdf_field":""},{"help":"Attach signed blank cancelled cheque","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":""}],"options":[],"required":null,"pdf_field":""},{"help":"Sign the mandate form","type":"signature","label":"Signature of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Fire and Special Perils, Business Interruption (Fire), Burglary & Housebreaking, Electronic Equipments, Machinery Breakdown, All Risk Insurance Sections, Baggage, Signage, Plate Glass, Money, Fidelity Guarantee, Employee Compensation, Public Liability, Personal Accident","attachments":["List of items with nature of damages","Detailed schedule of estimates of repairs and replacements","Copy of police report if applicable","Copy of claim notice for Directors and Officers Liability","Medical papers / disability certificate / post mortem report if applicable","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 endorsement.","No material information relevant to the claim has been withheld or not disclosed.","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 claim by the company.","The company reserves the right to process, reject or require further information for the claim."],"dropped_labels":7},"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/2398-business-secure-claim-form-notification-of-loss-or-damage"}