{"id":5480,"title":"Group Accident Protect - Micro Insurance Proposal Form - Credit Linked","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Group_Accident_Protect_Micro_Insurance_Proposal_Form_CL_ZK_V1_25_26_11082025_d38fdaea31.pdf","sha256":"beaa5785d9ddbcc126bd4973682f062ac18117b6939d0013941bbd33b037ffa3","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer such as a group administrator, bank, or financial institution to apply for group accident micro insurance coverage linked to credit. The proposer fills it to provide details about the insured persons, coverage options, and payment.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if more space is needed, indicating question numbers.","Use original and accurate information; misrepresentation may void the policy.","The insurer's acceptance of the proposal is subject to underwriting and premium receipt.","Payments will be processed only through electronic fund transfer after bank details are provided.","The form includes statutory warnings about prohibition of rebates under Insurance Act.","Signatures and dates are required at specified places.","The proposer should provide bank details for electronic fund transfer of payments and claims."],"title":"Group Accident Protect - Micro Insurance Proposal Form - Credit Linked","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Information","fields":[{"help":"Enter a valid email address","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Enter GSTIN if applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Name of the Authorised Signatory","type":"text","label":"Name:","options":[],"required":false,"pdf_field":""},{"help":"Designation of the Authorised Signatory","type":"text","label":"Designation:","options":[],"required":false,"pdf_field":""},{"help":"CKYC number of Authorised Signatory if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Full name of the proposer organization","type":"text","label":"Name of the Proposer/ Group Administrator/ Bank/ Financial Institution (Organisation/ Institute/ Association)*","options":[],"required":true,"pdf_field":""},{"help":"Describe the trade or business activity","type":"text","label":"Proposer’s Trade/ Business/ Activity*","options":[],"required":true,"pdf_field":""},{"help":"Registered office address line 1","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Registered office address line 2","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to the registered office","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of registered office","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of registered office","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Full registered office address","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of registered office","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of registered office","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Mailing address line 1 if different","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Mailing address line 2 if different","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to mailing address","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of mailing address","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of mailing address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Full mailing address","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of mailing address","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of mailing address","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile no.*","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide existing policy number if applicable","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Start date of policy period","type":"date","label":"Policy Period From:","options":[],"required":false,"pdf_field":""},{"help":"End date of policy period","type":"date","label":"To: Midnight of","options":[],"required":false,"pdf_field":""},{"help":"Duration of the policy","type":"text","label":"Policy Tenure","options":[],"required":false,"pdf_field":""},{"help":"Total number of insured persons","type":"number","label":"Number of Persons to be insured:","options":[],"required":false,"pdf_field":""},{"help":"Select sum insured basis","type":"choice","label":"Sum Insured Basis","options":["Fixed Sum Insured Basis","Reducing Sum Insured Basis"],"required":false,"pdf_field":""},{"help":"Select if installment payment option is chosen","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select installment frequency if applicable","type":"choice","label":"If Yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly","Annually"],"required":true,"pdf_field":""},{"help":"Specify type of credit","type":"text","label":"Type of Credit","options":[],"required":false,"pdf_field":""},{"help":"Enter quote number","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter branch code","type":"text","label":"Branch Code","options":[],"required":false,"pdf_field":""},{"help":"Date of quote","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"Sales manager code","type":"text","label":"Sales Manager Code","options":[],"required":false,"pdf_field":""},{"help":"Intermediary code","type":"text","label":"Intermediary Code","options":[],"required":false,"pdf_field":""},{"help":"Service RM code","type":"text","label":"Intermediary Service RM","options":[],"required":false,"pdf_field":""},{"help":"Intermediary branch code","type":"text","label":"Intermediary Branch code","options":[],"required":false,"pdf_field":""},{"help":"Business vertical of intermediary","type":"text","label":"Intermediary business vertical","options":[],"required":false,"pdf_field":""},{"help":"Client reference number","type":"text","label":"Intermediary Client Ref. No.","options":[],"required":false,"pdf_field":""},{"help":"Sales person name or code","type":"text","label":"SP Name/Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of the insured person","type":"text","label":"Insured Name*","options":[],"required":true,"pdf_field":""},{"help":"Name of the nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee to proposer","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of nominee","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Mobile number of nominee","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Email address of nominee","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Current address of nominee","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Permanent address of nominee","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Bank name and account details of nominee","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim for nominee","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name of appointee if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Date of birth of appointee","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Relationship of appointee to nominee","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""},{"help":"Name of nominee for appointee details","type":"text","label":"Name of the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Account number related to credit","type":"text","label":"Account No. with reference to credit","options":[],"required":true,"pdf_field":""},{"help":"Credit tenure","type":"text","label":"Tenure with reference to credit","options":[],"required":true,"pdf_field":""},{"help":"Name of financier","type":"text","label":"Name of the Financier","options":[],"required":true,"pdf_field":""},{"help":"Name of insured person","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Specify if applicant or co-applicant","type":"text","label":"Applicant / Co-applicant","options":[],"required":true,"pdf_field":""},{"help":"Select occupation type","type":"choice","label":"Occupation (Salaried/ Self-employed)","options":["Salaried","Self-employed"],"required":true,"pdf_field":""},{"help":"Date of birth of insured person","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Date credit was sanctioned","type":"date","label":"Credit sanctioned date","options":[],"required":true,"pdf_field":""},{"help":"Credit amount or outstanding amount","type":"amount","label":"Credit Amount / outstanding credit amount","options":[],"required":true,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Select sum insured basis","type":"choice","label":"Sum Insured Basis","options":["Fixed Sum Insured Basis","Reducing Sum Insured Basis"],"required":true,"pdf_field":""},{"help":"Specify any existing illness","type":"text","label":"Any existing illness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Details - Coverage Options","fields":[{"help":"Select Yes or No for each coverage option and specify sum insured limits where applicable","type":"table","label":"Coverage Opted - Please tick the Cover you wish to Opt for","options":["Accidental Death (AD)","Permanent Total Disablement (PTD)","Permanent Partial Disablement (PPD)","Temporary Total Disablement (TTD)","Carriage of Dead Body","Funeral Expenses","Accidental Medical Expenses Extension","Purchase of Blood","Transportation of imported medicine","Compassionate Visit","Disappearance Benefit","Modification of Residence / Vehicle","Cost of Support Items","Common Carrier","Children Education Grant","Accidental Dental Expenses","Convalescence Benefit","Domestic travel for medical treatment due to accident","Burns","Broken Bones","Coma","Loss of Employment due to accident","Monthly Pay out option","On Duty cover","Legal Expenses","Accidental Hospital Daily Cash Benefit","Accidental Hospitalization (inpatient)","Ambulance Charges","OPD Treatment","Sports Activity","Widowhood cover","Marriage expenses for Children"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or DD number if applicable","type":"text","label":"Cheque / DD#","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Bank on which cheque/DD is drawn","type":"text","label":"Drawn On","options":[],"required":false,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Bank name for payment","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Transaction reference number","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Provide previous policy period","type":"text","label":"Policy Period From - To","options":[],"required":false,"pdf_field":""},{"help":"Name of previous insurer","type":"text","label":"Name of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Number of members covered under previous policy","type":"number","label":"Number of Members Covered","options":[],"required":false,"pdf_field":""},{"help":"Total premium paid","type":"amount","label":"Total Premium (`)","options":[],"required":false,"pdf_field":""},{"help":"Total claims amount paid and outstanding","type":"amount","label":"Total amount of claims (Paid + Outstanding) (`)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details","fields":[{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Check if no existing bank account","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Check if cancelled cheque from other bank submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign here","type":"signature","label":"Signature of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Intermediary signature","type":"signature","label":"Signature of Intermediary/Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Proposer signature or thumb impression","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Agent signature and stamp","type":"signature","label":"Signature & Stamp as applicable of the Insurance Advisor/Specified person of Corporate Agent/Authorised Employee of Broker/Sales person*","options":[],"required":true,"pdf_field":""},{"help":"Proposer signature and stamp","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"},{"title":"Additional Declarations","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Are You or any of the proposed applicants or close relatives is/are associated to Politically Exposed Person (PEP)?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select type of organization","type":"choice","label":"In case of entity, Type of Organisation making the payment:","options":["Limited Company","International Organisation","Trust","Partnership","Section 25 Company","Non-Government Organisation (NGO)","Society","Others","Government Organisation","Co-operatives"],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":true,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"I hereby declare that, I am a person with a disability and require assistance in completing this proposal form. I authorize [Name of Representative], to act as my authorized representative and provide necessary declaration on my behalf for this Insurance Policy.","options":[],"required":false,"pdf_field":""},{"help":"Sign if applicable","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group Accident Protect - Micro Insurance - Credit Linked policies","attachments":["Additional sheets if more space is needed for answers","Cancelled Cheque for bank account details"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will be effective only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes sharing of proposal information with government and regulatory authorities.","Policy and service communications will be sent by email unless physical copy is requested.","The proposer consents to KYC verification through specified government portals.","The proposer confirms premiums are paid from legitimate sources and understands the insurer's rights under AML regulations.","The proposer declares if associated with Politically Exposed Persons or is a Non-Profit Organization as applicable.","The intermediary declares that the policy features and terms have been explained to the proposer.","The proposer may authorize a representative if a person with disability."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"care@zurichkotak.com","label":"Email Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/customer-support/grievance-redressal-process","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":"customer-care","channel":"phone","value":"1800 2120","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/customer-support/grievance-redressal-process","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":"customer-care","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/customer-support/grievance-redressal-process","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"},{"purpose":"customer-care","channel":"whatsapp","value":"7998879988","label":"WhatsApp Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/customer-support/grievance-redressal-process","quote":"t\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 chat only number.\nAccessibilit","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"grievanceofficer@zurichkotak.com","label":"Grievance Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://cms.zurichkotak.com/uploads/Policy_Wordings_CPI_dc7b416cf1.pdf","quote":"om .\nIn case the I nsured is not satisfied with the response, I nsured may contact the Grievance Officer of the ZKGI at grievanceofficer@zurichkotak.com . In case if the I nsured is not satisfied with the solution the\nGrievance Officer has provided, | I nsured | can write","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Unit no. 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East) Mumbai- 400063. Maharashtra, India.","label":"Registered & Corporate Office","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/","quote":"ker\nHealth portability\nResearch & Reports\nCorrespondence Address\nZurich Kotak General Insurance Company (India) Limited\nUnit no. 401, 4th Floor, Silver Metropolis,\nJai Coach Compound, Off Western Express Highway,\nGoregaon (East) Mumbai- 400063. Maharashtra, India.\nConnect with us\n: 022 - 69417220 (Toll number)\n: 1800 2120 (Toll free)\n+91-22-69417220 (IST 8 am to 8 pm)\nwww.zurichkot","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"care@zurichkotak.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://cms.zurichkotak.com/uploads/Policy_Wordings_CPI_dc7b416cf1.pdf","quote":"may contact the respective branch office of the ZKGI or may call toll free number 1800 2120 or may write an e - mail at care@zurichkotak.com .\nIn case the I nsured is not satisfied with the response, I nsured may contact the Grievance Officer of the ZKGI at gr","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"www.zurichkotak.com","label":"Grievance Redressal Process","level":null,"hours":null,"applies_to":"all","source_url":"https://cms.zurichkotak.com/uploads/Policy_Wordings_CPI_dc7b416cf1.pdf","quote":"nder.\nThe details of the Insurance Ombudsman/ complete Grievance Redressal Process is also available at ZKGI’s website: www.zurichkotak.com\nThe updated details of Insurance Ombudsman offices are also available on the website of | Council for\nInsurance Ombudsm","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/5480-group-accident-protect-micro-insurance-proposal-form-credit-linked"}