{"id":5483,"title":"Accident Care - Premium Plan Proposal Form","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/AC_Proposal_Form_Premium_Proposal_Form_ZK_V1_25_26_22042025_de17e43587.pdf","sha256":"144e372f7b5467112f6988ea258907350fa45637203958e2f6eb5f9ad8d04eb1","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Accident Care insurance policy from Zurich Kotak General Insurance Company. The proposer fills this form to provide personal, insurance, and payment details for policy issuance.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","Unanswered questions will be considered as 'Not Applicable'.","Attach additional sheets if more space is needed, indicating question number.","Use original documents for proofs and payments.","Electronic fund transfer is mandatory for payments and claims as per regulatory requirements.","Insurance is a subject matter of solicitation.","EIA account email ID is mandatory if opting for electronic insurance account."],"title":"Accident Care - Premium Plan Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Information","fields":[{"help":"","type":"choice","label":"Title","options":["Mr.","Miss.","Mrs.","Others"],"required":true,"pdf_field":""},{"help":"Fill in block letters","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Last Name","options":[],"required":false,"pdf_field":""},{"help":"Full name of proposer","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Include Address Line 1, Line 2, Nearest Landmark, City/District, State, Pin Code, Country","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if correspondence address differs from permanent address","type":"text","label":"Correspondence Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Emergency Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation*","options":["Salaried","Professionals","Student","Housewife","Retired","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Profession*","options":["Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Others","Business","CA"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Annual Income","options":["Upto 2.5 lacs","2.5 - 6 lacs","6 - 10 lacs","10 - 15 lacs","15 - 20 lacs","20 - 25 lacs",">25 lacs"],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Risk Category","options":["1","2","3"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable proofs","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [Tick (ü) whichever is applicable]","options":["PAN","Ration Card","Passport","Driving Licence","Voter ID Card","Others (Please specify)"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Customer Reference Number","type":"text","label":"If Yes, CRN","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Zurich / Kotak Group Employees","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If yes, Employee ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If yes, Policy No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Covers Available Under the Policy","fields":[{"help":"Write Yes or No","type":"yes-no","label":"Death Resulting from Accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Total Disablement (PTD) resulting from Accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Partial Disablement (PPD) resulting from Accident","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured (`)","options":[],"required":true,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Carriage of Dead Body","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Children’s Education Grant","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Ambulance Charges","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Accidental Hospital Daily Cash Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Accidental Hospitalization Expenses Reimbursement","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Convalescence Benefit","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"Full name of insured person","type":"text","label":"Name in Full*","options":[],"required":true,"pdf_field":""},{"help":"Relation to proposer","type":"text","label":"Relation with the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["M","F"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income (`)*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status*","options":[],"required":true,"pdf_field":""},{"help":"If not created, visit https://healthid.ndhm.gov.in/ to create","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Insurance Details","fields":[{"help":"Provide policy numbers of similar policies held","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Policy Start Date","options":[],"required":false,"pdf_field":""},{"help":"Name of insured under other policies","type":"text","label":"Name in Full","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policies","type":"amount","label":"Policy Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Total share percentage of all policies","type":"number","label":"Total % share cannot exceed more than 100%","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Nominee","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"","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, Date of Birth, Relationship with Nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Total Premium (`)","options":[],"required":false,"pdf_field":""},{"help":"For past claims","type":"text","label":"Nature of loss","options":[],"required":false,"pdf_field":""},{"help":"For past claims","type":"amount","label":"Total Amount of claims (`)","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount (`)","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Bank name on cheque/DD","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"","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":"Bank Account Details for Electronic Fund Transfer","fields":[{"help":"Bank account number for EFT","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Tick if no bank account exists","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Tick 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 Consents","fields":[{"help":"","type":"signature","label":"Signature / Thumb impression of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Accident Care - Premium Plan","attachments":["Additional sheets if space is insufficient to complete details","Cancelled Cheque (if applicable)","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["The information provided is true, complete, and forms the basis of the insurance policy.","The policy will come into force only after full payment of the premium.","Notify in writing any change in occupation or health after submission but before acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical records with government/regulatory authorities.","Policy and service communications will be sent by email unless physical copy requested.","Consent to verify identity/address through government or regulatory portals for KYC.","Declaration of High Net Worth Individual status if applicable.","All premiums paid are from bonafide sources and not from proceeds of crime under PMLA.","Consent to block premium under BIMA ASBA facility and debit from bank account upon acceptance.","Acknowledgement that submission of proposal or payment does not oblige policy issuance.","Declaration for persons with disability authorizing representative to assist in form completion.","Agent declaration confirming explanation of proposal form and policy terms to proposer.","Statutory warning on prohibition of rebates under Insurance Act 1938."],"dropped_labels":2},"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/5483-accident-care-premium-plan-proposal-form"}