{"id":5486,"title":"Arogya Sanjeevani Policy, Zurich Kotak General Insurance Company (India) Limited 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/Arogya_Sanjeevani_Policy_Proposal_Form_ZK_V1_25_26_22042025_664ef4b508.pdf","sha256":"492cc3ef822d711f675708fb56a0c99578d8be1ef588cd35d29d65ca92b642e5","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for health insurance under the Arogya Sanjeevani Policy by Zurich Kotak General Insurance Company. It is filled by the proposer who wishes to purchase the insurance policy.","notes":["Fill the proposal form in BLOCK LETTERS.","Fields marked with * are mandatory.","Submission of this form does not guarantee acceptance of the proposal.","Provide all information fully, accurately and correctly.","Attach additional sheets if needed and indicate question number.","Online or credit card premium payment must be made by the policyholder; third party payments not allowed.","Use original documents for continuous medication or hospitalization proof.","Total percentage share of insured persons cannot exceed 100%.","Electronic fund transfer details must be provided for payment processing.","Agent must explain policy features and terms to proposer before signature.","Prohibition of rebates under Section 41 of Insurance Act applies.","If proposer is person with disability, authorized representative can assist in form completion."],"title":"Arogya Sanjeevani Policy, Zurich Kotak General Insurance Company (India) Limited Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"post / in person / through intermediary","address":"Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. Maharashtra, India"},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"","type":"choice","label":"Type of Cover*","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Note: POS is applicable for Sum Insured up to 5 Lakhs","type":"choice","label":"Base Sum Insured*","options":["50 K","1 Lac","1.5 Lac","2 Lac","2.5 Lac","3 Lac","3.5 Lac","4 Lac","4.5 Lac","5 Lac","5.5 Lac","6 Lac","6.5 Lac","7 Lac","7.5 Lac","8 Lac","8.5 Lac","9 Lac","9.5 Lac","10 Lac","PASP"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if Installment Option is Yes","type":"choice","label":"Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":false,"pdf_field":""},{"help":"Format: DD MM YYYY","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer’s Information","fields":[{"help":"","type":"choice","label":"Title","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":false,"pdf_field":""},{"help":"First Name, Middle Name, Last Name","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Address Line 1, Address Line 2, Nearest Landmark, City/District, State, Pin Code, Country","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if Correspondence Address is different","type":"text","label":"Correspondence Address*","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Occupation*","options":["Salaried","Professionals","Student","Housewife","Retired","Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Business","CA","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Profession*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","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":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":false,"pdf_field":""},{"help":"Format: DD MM YYYY","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"Columns: Name in Full*, Relation with the Proposer*, Date of Birth DD/MM/YYYY*, Height (in cm)*, Occupation*, Gender*, Weight (in kg)*, Marital Status*, ABHA Number. Total % share cannot exceed 100%.","type":"table","label":"Insured Details","options":[],"required":true,"pdf_field":""},{"help":"Name*, Relationship with Proposer*, Date of Birth DD/MM/YYYY*, Mobile Number, Email ID, Present Address, Permanent Address, Bank Name and Account Details, % of claim share*.","type":"text","label":"Nominee Details","options":[],"required":true,"pdf_field":""},{"help":"","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":"If Yes, provide CRN","type":"choice","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide Employee ID and Policy No.","type":"choice","label":"Zurich / Kotak Group Employees","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Fill if payment mode is Cheque or Demand Draft","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Bank name for Cheque / Demand Draft","type":"text","label":"Drawn On","options":[],"required":false,"pdf_field":""},{"help":"Date of payment instrument","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":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Fill if payment mode is Credit Card","type":"text","label":"For Credit / Debit Card - Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of credit card transaction","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Hospitalisation Information","fields":[{"help":"Includes questions on current health, past illnesses, medication, diabetes, high BP, cholesterol, medical tests, hospitalizations, and specific diseases. Fill Yes/No and details as applicable.","type":"table","label":"Section A: Medical and Hospitalisation Information","options":[],"required":null,"pdf_field":""},{"help":"Information on smoking/tobacco and alcohol consumption including duration and quantity per day.","type":"text","label":"Section B: Lifestyle Information","options":[],"required":null,"pdf_field":""},{"help":"Type of policy, period of insurance, insurance company, base annual sum insured.","type":"text","label":"Section C: Existing Health Insurance Details","options":[],"required":null,"pdf_field":""},{"help":"Details of ailment for which claim was made, claim amount paid/rejected, year of claim.","type":"table","label":"Section D: Details of claims","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any.","type":"text","label":"Any Pre-existing diseases","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"","type":"choice","label":"Do you have an EIA Account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Mandatory","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Type of Organisation (if entity)","fields":[{"help":"","type":"choice","label":"Type of Organisation","options":["Trust","Partnership","Limited Company","International Organisation","Government Organisation","Co-operatives","Non-Government Organisation (NGO)","Section 25 Company","Society","Others"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Format: DD MM YYYY","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details for Electronic Fund Transfer","fields":[{"help":"For electronic fund transfer of payments and claims","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Bank details as per premium cheque to be used for electronic fund transfer","options":["Cancelled Cheque submitted of Other Bank","No existing Bank Account#"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations for Agent and Proposer with Disability","fields":[{"help":"Agent declaration","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":"","type":"signature","label":"Signature / Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Name of authorized representative and declaration","type":"text","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":false,"pdf_field":""}],"filled_by":"agent / proposer"},{"title":"Statutory and Vernacular Declarations","fields":[{"help":"For statutory warning and rebate prohibition","type":"signature","label":"Signature / Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Declaration by intermediary","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Format: DD MM YYYY","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"},{"title":"Additional Declarations","fields":[{"help":"PEP means individuals with prominent public functions","type":"choice","label":"Are You or any of the proposed applicants or close relatives associated to Politically Exposed Person (PEP)?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Non-profit organization as defined under Income-tax Act","type":"choice","label":"Are you a Non-Profit Organization?* (only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Arogya Sanjeevani Policy health insurance proposals","attachments":["Additional sheets if space is insufficient to complete details","Documents for any continuous medication or hospitalization mentioned","Cancelled Cheque for electronic fund transfer (if applicable)","Insurance Repository Application form (if opting to create EIA account)"],"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 premium.","Notify the company in writing of 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 insurer, TPA and regulatory authorities.","Policy and service communications will be sent in soft copy to the email provided unless physical copy requested.","Consent to verify identity/address through government portals for KYC.","Consent to share medical records via ABHA number if available.","Declaration of High Net Worth Individual status if applicable.","AML declaration confirming premiums paid from bonafide sources and compliance with money laundering laws.","Consent to block premium payment under BIMA ASBA facility and debit from bank account upon acceptance."],"dropped_labels":5},"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/5486-arogya-sanjeevani-policy-zurich-kotak-general-insurance-company-india-limited-pr"}