{"id":5487,"title":"Accident Care - Excel 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_Excel_Proposal_Form_ZK_V1_25_26_22042025_63009c24c0.pdf","sha256":"3cb031521ae09359473f2e7d25c0ed248e760f1506fb7918feeebed7e2fa7493","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 with personal, insured, and payment details to apply for the policy.","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.","Insurance is a subject matter of solicitation.","Original or cancelled cheque required for electronic fund transfer details.","Policy issuance is at the sole discretion of the company and subject to underwriting policy.","Premium must be received in full and realized for policy to be effective.","Use the email provided for all regulatory and policy servicing communications unless physical copy requested."],"title":"Accident Care - Excel Plan Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","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":"Proposer's Information","fields":[{"help":"","type":"choice","label":"Title","options":["Mr.","Miss.","Mrs.","Others"],"required":true,"pdf_field":""},{"help":"","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":true,"pdf_field":""},{"help":"Include 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":"yes-no","label":"Is Correspondence Address same as Permanent Address?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if correspondence address is different from permanent address; include Address Line 1, Address Line 2, Nearest Landmark, City/District, State, Pin Code, Country","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":"Provide PAN or Form 60 if no PAN","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","type":"date","label":"Date of Birth","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"],"required":false,"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":"","type":"yes-no","label":"Permanent Total Disablement (PTD) resulting from Accident - Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured (`)","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Insured Information","fields":[{"help":"","type":"text","label":"Name in Full","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relation with the Proposer","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of Birth","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 details for up to 4 insurers if applicable","type":"text","label":"Name & Address of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Policy Period From","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Total Premium (`)","options":[],"required":false,"pdf_field":""},{"help":"Loss details for past 3 years","type":"text","label":"Nature of loss","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Total Amount of claims (`)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"","type":"text","label":"Name of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship of Nominee with Proposer","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Nominee Date of Birth","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":"Total % share cannot exceed 100%","type":"number","label":"% of claim share","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details and Payment Details","fields":[{"help":"","type":"yes-no","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":"","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"If Yes, fill Insurance Repository Application form","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Cheque / DD No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":true,"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"],"required":false,"pdf_field":""},{"help":"Account No., Bank Name, IFSC/MICR Code, Account Holder Name","type":"text","label":"Particulars of Bank Account","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Consent to block premium payable under BIMA ASBA facility","type":"checkbox","label":"ASBA Declaration","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Acknowledgement","fields":[{"help":"Name of proposer","type":"text","label":"Received from Ms./Mrs./ Mr","options":[],"required":false,"pdf_field":""},{"help":"Amount received","type":"amount","label":"a sum of `","options":[],"required":false,"pdf_field":""},{"help":"Payment mode","type":"text","label":"through Cheque/DD","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Zurich Kotak General Insurance Company (India) Limited Official / Intermediary","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"HH:MM","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"insurance company official / intermediary"},{"title":"Declarations","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","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Confirms explanation of form and terms to proposer","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","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":"yes-no","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":"yes-no","label":"Are you a Non-Profit Organization? (only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick only if applicable","type":"checkbox","label":"I hereby declare that I qualify as a High Net Worth Individual (HNI), with a net worth of ₹50 crore or more","options":[],"required":false,"pdf_field":""},{"help":"Confirm premiums paid from bonafide sources and no proceeds of crime","type":"checkbox","label":"AML Declaration","options":[],"required":true,"pdf_field":""},{"help":"","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":""}],"filled_by":"proposer"},{"title":"Declaration in case the proposer/policyholder is person with disability (PWD)","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Declaration for Agent","fields":[{"help":"Confirms explanation of policy features and terms to proposer","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":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Accident Care insurance policy","attachments":["Additional sheets if space is insufficient to complete details","Cancelled Cheque for electronic fund transfer (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 proposal submission but before risk acceptance.","Consent to company seeking medical and other information for underwriting and claim settlement.","Consent to share proposal and medical information with government 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 proof through government portals for KYC.","Declaration of High Net Worth Individual status if applicable.","AML declaration confirming premiums paid from bonafide sources and no proceeds of crime.","Consent to block premium payment under BIMA ASBA facility if applicable.","Agent declaration confirming explanation of policy terms to proposer.","Declaration in case proposer is person with disability authorizing representative to assist."],"dropped_labels":6},"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/5487-accident-care-excel-plan-proposal-form"}