{"id":5490,"title":"Accident Care - Prime 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_Prime_Proposal_Form_ZK_V1_25_26_22042025_65908f452a.pdf","sha256":"7be1528c791316b5b7c774f1cfbbadf4971f4098cd5628f9e10dee6ca99e600c","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for an Accident Care insurance policy to be filled by the person seeking insurance (proposer) and includes details about the insured persons, coverage options, and declarations.","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 proof of identity and address.","Electronic Insurance Account email ID is mandatory.","Premium payments must be realized in full and in time for policy to be effective.","Insurance is a subject matter of solicitation."],"title":"Accident Care - Prime 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 is different 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":"Goods and Services Tax Identification Number if applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation","options":["Salaried","Professionals","Student","Housewife","Retired","Others","Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Business","CA"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Profession","options":["Salaried","Professionals","Student","Housewife","Retired","Others","Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","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 or Form 60 if PAN not available","type":"text","label":"PAN Number","options":[],"required":true,"pdf_field":""},{"help":"Central KYC Registry number if available","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":"Select applicable documents","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":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":"Insured Information","fields":[{"help":"Full name of insured person","type":"text","label":"Name in Full","options":[],"required":true,"pdf_field":""},{"help":"Relationship 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","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":["Single","Married","Others"],"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":"Nominee Details","fields":[{"help":"","type":"text","label":"Nominee Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship of Nominee with Proposer","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","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":"For claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Total share for all nominees cannot exceed 100%","type":"number","label":"% of claim share","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Nominee","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":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Total Disablement (PTD) resulting from Accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Partial Disablement (PPD) resulting from Accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Temporary Total Disablement (TTD) resulting from Accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify sum insured amount","type":"amount","label":"Sum Insured (`)","options":[],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Carriage of Dead Body","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Total Disablement Improvement Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Permanent Partial Disablement Improvement Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Children’s Education Grant","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Ambulance Charges","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Funeral Expenses","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Accidental Hospital Daily Cash Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Accidental Hospitalization Expenses Reimbursement","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write Yes or No","type":"yes-no","label":"Convalescence Benefit","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Insurance Details","fields":[{"help":"Columns: Sr. No., Name in Full, Insurer, Policy No., Policy Start Date, Policy Period From-To, Policy Sum Insured, Total Premium (`), Nature of loss, Total Amount of claims (`)","type":"table","label":"Details of similar policies held by the persons to be insured","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"If payment by cheque or DD","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Premium amount","type":"amount","label":"Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Bank name for cheque/DD","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch for cheque/DD","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":"Electronic Insurance Account 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":"Mandatory","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":""}],"filled_by":"proposer"},{"title":"Bank Account Details","fields":[{"help":"For electronic fund transfer","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 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":"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":"Confirms explanation of form contents to proposer","type":"signature","label":"Signature of Intermediary / Sales Person","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Accident Care insurance policy","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.","Policy comes into force only after full payment of premium.","Notify in writing any change in occupation or health after proposal 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 and regulatory authorities.","Policy and service communications will be sent by email unless physical copy requested.","Consent to verify identity/address through government portals for KYC.","Proposer may be classified as High Net Worth Individual if declared.","All premiums paid from bonafide sources; company may cancel contract if money laundering detected.","Consent to block premium payment under BIMA ASBA facility and debit from bank account upon acceptance.","No rebates or inducements allowed under Insurance Act 1938; violations punishable by fine.","Intermediary confirms proposer has understood the proposal form and policy terms."],"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/5490-accident-care-prime-plan-proposal-form"}