{"id":5485,"title":"Group Accident Protect - Micro Insurance 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_Micro_Insurance_Proposal_Form_NCL_ZK_V1_25_26_11082025_2771c0e648.pdf","sha256":"b761b556b070d79195d40bccbe4d925bff6553aa6116465ba34fa4ef09bca17d","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer such as a group administrator, bank, financial institution, or organization to apply for group accident micro insurance coverage for multiple insured persons.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Use additional sheets if needed and indicate question number.","Submission of this form or payment does not guarantee policy issuance.","Policy is subject to underwriting and receipt of premium in full and on time.","Electronic fund transfer details must be provided for payment processing.","Politically Exposed Person (PEP) status must be declared if applicable.","Non-profit organization status must be declared if applicable."],"title":"Group Accident Protect - Micro Insurance 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 legal name of the proposer entity","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 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 if different from registered office","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":"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 proposer has existing policy with 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 covered under the policy","type":"number","label":"Number of Persons to be insured:","options":[],"required":false,"pdf_field":""},{"help":"Select if premium payment in installments is desired","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Frequency of installment payments","type":"choice","label":"If Yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"List categories of insured persons","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, and 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 or outstanding under previous policy","type":"amount","label":"Total amount of claims (Paid + Outstanding) (`)","options":[],"required":false,"pdf_field":""},{"help":"Membership or employee ID under previous policy","type":"text","label":"Membership ID/ Employee Number","options":[],"required":false,"pdf_field":""},{"help":"Category of insured persons under previous policy","type":"text","label":"Category","options":[],"required":false,"pdf_field":""},{"help":"Name of insured person under previous policy","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 to insured person","type":"text","label":"Relationship with the Insured Person","options":[],"required":false,"pdf_field":""},{"help":"Occupation or designation of insured person","type":"text","label":"Designation/ Occupation","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under previous policy","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Existing illnesses of insured person","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 Yes or No for each coverage option and specify sum insured limits","type":"table","label":"Coverage Opted - Please tick the Cover you wish to Opt for","options":["Yes","No"],"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":"Tick if no bank account exists","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Signature of the proposer","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":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary/Sales Person*","options":[],"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 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 and intermediary"}],"deadlines":[],"applies_to":"Group Accident Protect - Micro Insurance - Non Credit Linked policies","attachments":["Additional sheets if more space is required to answer any question","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.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes sharing of proposal and medical information with regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","The proposer consents to KYC verification through government portals.","All premiums are paid from legitimate sources and comply with anti-money laundering laws.","No rebates or inducements are allowed as per Insurance Act 1938.","If proposer is a person with disability, they may authorize a representative to assist in form completion."],"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/5485-group-accident-protect-micro-insurance-proposal-form-non-credit-linked"}