{"id":5500,"title":"CYBER SECURE 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/Cyber_Secure_Proposal_Form_4a45d4fe6a.pdf","sha256":"31f011250e49ed264d55dda121ca0c988c9a59a3f87044157273a7f62b4989f9","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Cyber Secure insurance to be filled by the individual policyholder applying for coverage.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","If additional space is needed, attach extra sheets and indicate the question number.","Submission of the proposal or payment does not oblige the company to issue a policy.","If the proposal is not accepted, payment will be refunded without interest.","Use original documents for proofs.","Email id is mandatory for EIA account details.","Total nominee share percentage cannot exceed 100%.","Family Cover is limited to spouse and a maximum of two children below 18 years."],"title":"CYBER SECURE PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Applicant’s Details","fields":[{"help":"Enter the quote number provided","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of the quote","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Sales Manager Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Service RM","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Branch code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary business vertical","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Client Ref No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"SP Name / Code","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Title Mr. / Miss / Mrs. / M/s / Others","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":null,"pdf_field":""},{"help":"Enter full name: First Name, Middle Name, Last Name","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality ##","options":["Indian","Non-Indian","NRI"],"required":null,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id:","options":[],"required":null,"pdf_field":""},{"help":"Enter full permanent address including Address Line 1, Line 2, Landmark, City/District, State, Pin Code, Country","type":"text","label":"Permanent Address *","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Postal Address same as the Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter PAN number or tick if Form 60 is submitted","type":"text","label":"PAN* / Form 60 (only in case the customer does not have PAN No.)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter GSTIN if applicable","type":"text","label":"GSTIN:","options":[],"required":null,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Additional Applicant Details and Cover Options","fields":[{"help":"Select annual income range","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":null,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable identity and address proofs","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [Tick (✓) whichever is applicable]","options":["PAN","Aadhaar","Passport","Driving License","Voter ID","Others (specify)"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter Customer Relationship Number if applicable","type":"text","label":"If ‘Yes’, CRN","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Zurich/ Kotak Group Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter employee ID if applicable","type":"text","label":"If ‘Yes’, Employee ID","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter existing policy number if applicable","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":null,"pdf_field":""},{"help":"Select cover type; Family Cover limited to spouse and max two children under 18","type":"choice","label":"Please tick the type of Cover You want to opt for?","options":["Individual Cover","Family Cover"],"required":null,"pdf_field":""},{"help":"Provide Name and Relationship with Proposer for up to 4 family members","type":"table","label":"Please share the details of the family members","options":[],"required":null,"pdf_field":""},{"help":"Select coverage option","type":"choice","label":"Please select the Coverage You want to opt for?","options":["Option 1: Digital Theft of Funds","Option 2: All Covers"],"required":null,"pdf_field":""},{"help":"Enter sum insured amount in INR","type":"amount","label":"Specify the Sum Insured (Limit of Liability) You want to opt for? INR","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do You wish to opt for Additional Cover - Identity Theft (Cover is limited to 10% of the Limit of Liability opted)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick all applicable preventive service benefits","type":"checkbox","label":"Please select the Benefits required under Preventive Services","options":["Identity Monitoring","Cyber education","Cyber Training","Incident Response – Helpline","Incident Response – Online Guided Version","Digital Health Check","Attack Surface Management","Wi-fi Scan","Safe Browsing","Endpoint Protection (iOS & Android)","Service Provider education and awareness content","QR Code Scanner"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you or your family (if applicable) ever been a victim of online fraud or cyber bullying/ defamation or have any of your Computer Systems been hacked or compromised?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of the incident","type":"text","label":"If 'Yes', please provide details","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you or your family (if applicable) aware of any circumstances which is likely to lead to you suffering a loss or a claim being made against you which would be covered under this policy you are applying for?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of the claim or lawsuit","type":"text","label":"If 'Yes', please provide details","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Nominee Details and Bank Account Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Nominee Name *","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship of Nominee with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account details of nominee","type":"text","label":"Nominee Bank Account Details","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage share for nominee; total must not exceed 100%","type":"number","label":"% share","options":[],"required":null,"pdf_field":""},{"help":"Provide name, date of birth, and relationship of appointee with nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Payment Details and Refund / Claims Detail","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"Enter amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter name of bank or payee","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Enter date of payment","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Bank and Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter account holder's name","type":"text","label":"Account Holder name","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction reference number for online payment","type":"text","label":"Transaction Reference No","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction date for online payment","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter EIA number if applicable","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":null,"pdf_field":""},{"help":"Enter name of insurance repository","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter email registered with insurance repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declarations and Signatures","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature and stamp of insurance advisor or sales person","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":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary/ Sales Person","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder and intermediary"},{"title":"AML Declaration and Other Declarations","fields":[{"help":"Select type of organization if applicable","type":"choice","label":"Type of Organisation making the payment","options":["Limited Company","Government Organisation","Non-Government Organisation (NGO)","Society","Trust","Partnership","International Organisation","Co-operatives","Section 25 Company","Others"],"required":null,"pdf_field":""},{"help":"Select Yes or No","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":"Select Yes or No","type":"yes-no","label":"Are you a Non-Profit Organization? (only in case of an entity)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Cyber Secure insurance policy","attachments":["Additional sheets if space is insufficient to complete details","Insurance Repository Application form (if opting for EIA account creation)"],"declarations":["The statements made in this Proposal Form are true to the best of the proposer’s knowledge and belief.","The proposal forms the basis of the contract between the proposer and Zurich Kotak General Insurance Company (India) Limited.","The company’s liability commences only after acceptance of the proposal and receipt of premium.","The company may void the policy if any information is untrue, incorrect, or incomplete.","Premiums have been/will be paid from bonafide sources and not from proceeds of crime under the Prevention of Money Laundering Act.","The company has the right to verify identity and address proofs through various government portals.","Policy and service communications will be sent in soft copy to the email provided unless physical copy is requested.","No rebates are allowed as per Section 41 of the Insurance Act 1938.","The proposer consents to the company verifying identity/address through Central KYC Registry or other portals."],"dropped_labels":8},"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/5500-cyber-secure-proposal-form"}