{"id":5482,"title":"Group Accident Protect Proposal Form - Non 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_Proposal_Form_NCL_ZK_V1_25_26_11082025_cdc152e774.pdf","sha256":"ee3c12c6d6bf42e016060e97a96fb47a456a65bb86aafcd0535292617d39370c","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Group Accident Protect insurance to be filled by the proposer or group administrator seeking insurance coverage for a group of persons.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Submission of this form does not guarantee policy issuance.","Attach additional sheets if space is insufficient, indicating question number.","Use original documents and provide accurate information to avoid policy voidance.","Policy issuance is subject to underwriting and receipt of premium.","Electronic fund transfer details must be provided for payment processing.","Policy and service communications will be sent via email unless physical copy is requested."],"title":"Group Accident Protect Proposal Form - Non Credit Linked","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer's Information","fields":[{"help":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number of the proposer","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":"For Authorised Signatory","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Full name of the proposer or group administrator","type":"text","label":"Name of the Proposer/ Group Administrator/ Bank/ Financial Institution (Organisation/ Institute/ Association)*","options":[],"required":true,"pdf_field":""},{"help":"Nature of business or activity of the proposer","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 if mailing address is same as registered office","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 for mailing address","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district for mailing address","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State for 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 for mailing address","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code for mailing address","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Email address of proposer","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Goods and Services Tax Identification Number","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you have an existing policy with the insurer","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"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":"Total number of persons to be insured","type":"number","label":"Number of Persons to be insured:","options":[],"required":false,"pdf_field":""},{"help":"Select if premium installment option is chosen","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Frequency of installment payment","type":"choice","label":"If Yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"List categories of insured persons (Cat 1 to Cat 6)","type":"table","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, Trust etc.)","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 between nominee and 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 details of nominee for claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim for nominee (total must not exceed 100%)","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name, DOB, relationship of appointee for minor nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Policy period for past policies","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 for previous policy","type":"amount","label":"Total Premium (`)","options":[],"required":false,"pdf_field":""},{"help":"Total claims paid and outstanding","type":"amount","label":"Total amount of claims (Paid + Outstanding) (`)","options":[],"required":false,"pdf_field":""},{"help":"Membership or employee ID","type":"text","label":"Membership ID/ Employee Number","options":[],"required":false,"pdf_field":""},{"help":"Category of insured person","type":"text","label":"Category","options":[],"required":false,"pdf_field":""},{"help":"Name of insured person","type":"text","label":"Name of the Insured Person","options":[],"required":false,"pdf_field":""},{"help":"DOB of insured person","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Gender of insured person","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":false,"pdf_field":""},{"help":"Relationship with insured person","type":"text","label":"Relationship with the Insured Person","options":[],"required":false,"pdf_field":""},{"help":"Designation or occupation of insured person","type":"text","label":"Designation/ Occupation","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for the person","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Existing illness if any","type":"text","label":"Any existing illness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or Demand Draft number","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":"Branch of bank","type":"text","label":"Bank Branch","options":[],"required":false,"pdf_field":""},{"help":"Transaction reference number for card payment","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of card 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":"Risk Details and Coverage Options","fields":[{"help":"Select the covers you want to opt for","type":"choice","label":"Coverage Opted - Please tick the Cover you wish to Opt for","options":["Accidental Death (AD) - Yes/No","Permanent Total Disablement (PTD) - Yes/No","Permanent Partial Disablement (PPD) - Yes/No","Temporary Total Disablement (TTD) - Yes/No","Carriage of Dead Body - Yes/No","Funeral Expenses - Yes/No"],"required":false,"pdf_field":""},{"help":"Sum insured amount for each cover","type":"amount","label":"Sum Insured Limits","options":[],"required":false,"pdf_field":""},{"help":"Optional covers to be selected if desired","type":"checkbox","label":"Section B – Optional Covers to Section A","options":["Carriage of Dead Body","Funeral Expenses"],"required":false,"pdf_field":""},{"help":"Select benefits to be included","type":"checkbox","label":"Section C – Benefits","options":["Domestic travel for medical treatment due to accident","Loss of Employment due to accident*","Monthly Pay out option","Burns","Broken Bones","Coma","On Duty cover","Legal Expenses","Accidental Hospital Daily Cash Benefit","Accidental Hospitalization (inpatient)","Accidental Dental Expenses","Children Education Grant","Marriage expenses for Children","Sports Activity","Ambulance Charges","OPD Treatment","Convalescence Benefit","Widowhood cover","Common Carrier","Modification of Residence / Vehicle","Cost of Support Items","Transportation of imported medicine","Compassionate Visit","Disappearance Benefit","Accidental Medical Expenses Extension","Purchase of Blood"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details and Declarations","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":"Tick if no existing bank account","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"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":"Signature of the proposer","type":"signature","label":"Signature of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Declare if any applicant or close relative is a PEP","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":"Declare if proposer is a non-profit organization","type":"yes-no","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary/Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Signature and stamp of insurance advisor or agent","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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group Accident Protect - Non Credit Linked policies","attachments":["Additional sheets if more space is required to answer questions","Cancelled Cheque for bank account verification"],"declarations":["The proposer declares that all information provided is true, complete and accurate to the best of their knowledge.","The policy will be issued only after acceptance of the proposal and full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent is given to the company to seek medical and other information for underwriting and claims.","Consent is given to share proposal information with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","Consent is given to verify identity/address through government portals for KYC.","All premiums are paid from bonafide sources and not from proceeds of crime as per AML regulations.","The proposer agrees to the ASBA facility for premium payment if applicable.","The proposer confirms understanding of the proposal form and policy terms.","The intermediary confirms explaining the policy features and terms to the proposer.","No rebates or inducements are allowed as per Insurance Act Section 41.","If proposer is a person with disability, they may authorize a representative to assist in form completion."],"dropped_labels":0},"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/5482-group-accident-protect-proposal-form-non-credit-linked"}