{"id":5503,"title":"Employees Compensation Insurance 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/Employees_Compensation_Insurance_Proposal_Form_ZK_26_27_v1_17032026_1_d3d284b26b.pdf","sha256":"ff7d035057b9ada2a6d162937eba418dcf371fdd02ec82cd8121c6687b286785","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or corporate entities to apply for Employees Compensation Insurance coverage from Zurich Kotak General Insurance Company. The proposer fills it to provide details about their business, employees, and coverage requirements.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient.","Use original documents for proofs.","Electronic communication will be sent to the email provided unless physical copy is requested.","The company’s liability starts only after acceptance of the proposal and receipt of premium.","Total nominee share percentage must not exceed 100%.","If proposer is a person with disability, an authorized representative may assist in filling the form."],"title":"Employees Compensation Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Details","fields":[{"help":"Enter full legal name of the proposer in block letters","type":"text","label":"Proposer’s Names in full*","options":[],"required":true,"pdf_field":""},{"help":"Specify the trade or occupation of the proposer","type":"text","label":"Proposer's Trade or Occupation *","options":[],"required":true,"pdf_field":""},{"help":"Describe the work activities to be insured","type":"text","label":"Particulars of work to be covered in Detail:","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid contact phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Enter the first line of the registered or permanent address","type":"text","label":"Registered Office Address / Permanent Address* - Address (Line 1)","options":[],"required":true,"pdf_field":""},{"help":"Enter the second line of the registered or permanent address","type":"text","label":"Registered Office Address / Permanent Address* - Address (Line 2)","options":[],"required":true,"pdf_field":""},{"help":"Provide a nearby landmark for the address","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter city or district name","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Communication Address same as the Registered Office Address / Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter state if communication address differs","type":"text","label":"If ‘No’, please provide below - State","options":[],"required":null,"pdf_field":""},{"help":"Enter full communication postal address","type":"text","label":"Communication (Postal) Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter GST Identification Number if applicable","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number or attach Form 60 if no PAN","type":"text","label":"For Individual customers, please share below details: PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Tick if Form 60 is submitted instead of PAN","type":"checkbox","label":"Form 60 (only in case the customer does not have PAN No.)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter GSTIN for individual if applicable","type":"text","label":"GSTIN:","options":[],"required":null,"pdf_field":""},{"help":"Select occupation category","type":"choice","label":"Occupation","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":null,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"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":"Indicate if you have an existing policy with the insurer","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide existing policy number","type":"text","label":"If ‘Yes’, Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable identity and address proofs","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [(ü) Tick whichever is applicable]","options":["PAN","Aadhaar","Passport","Driving Licence","Voter ID Card","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"Enter corporate PAN","type":"text","label":"For Corporate customers, please share below details: PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Enter corporate GSTIN","type":"text","label":"GSTIN:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of authorized signatory","type":"text","label":"Please share the below details for the Authorised Signatory: Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter designation of authorized signatory","type":"text","label":"Designation:","options":[],"required":null,"pdf_field":""},{"help":"Enter CKYC number of authorized signatory if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":null,"pdf_field":""},{"help":"Enter first line of risk location address","type":"text","label":"Risk Location address * - Address (Line 1)","options":[],"required":true,"pdf_field":""},{"help":"Provide landmark near risk location","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter city or district of risk location","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"Enter country of risk location","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Enter state of risk location","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code of risk location","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter policy start date","type":"date","label":"Policy Period: From","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage’s Required","fields":[{"help":"Enter limit per employee for occupational diseases","type":"amount","label":"Occupational Diseases - Limit Per Employee `","options":[],"required":null,"pdf_field":""},{"help":"Tick if coverage for contractors employees is opted","type":"checkbox","label":"Contractors Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify any other optional cover desired","type":"text","label":"Any other Optional cover you wish to opt for Please specify","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Own Employee Details","fields":[{"help":"Describe employee categories","type":"text","label":"Description of Employees","options":[],"required":null,"pdf_field":""},{"help":"Enter total number of employees declared","type":"number","label":"Declared Number of Employees","options":[],"required":null,"pdf_field":""},{"help":"Enter total wages amount","type":"amount","label":"Total Declared Wages during the period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter location(s) of employment","type":"text","label":"Place or Places of Employment","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Contractors Employee Details (if coverage opted)","fields":[{"help":"Enter contractor's name","type":"text","label":"Contractors Name","options":[],"required":null,"pdf_field":""},{"help":"Enter contractor's registered address","type":"text","label":"Registered Address","options":[],"required":null,"pdf_field":""},{"help":"Enter number of contractor's employees","type":"number","label":"Declared Number of Employees","options":[],"required":null,"pdf_field":""},{"help":"Enter total wages paid to contractor's employees","type":"amount","label":"Total Declared Wages during the period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter location(s) of contractor's employment","type":"text","label":"Place or Places of Employment","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Wages and Accidents History","fields":[{"help":"Provide yearly wages and loss amounts for past 3 years","type":"table","label":"State the total Wages paid and particulars of accidents to your employees during the past three years. Year [Past 3 years from this date], Wages Paid, Amount of Loss","options":[],"required":null,"pdf_field":""},{"help":"Indicate if all employees are included","type":"yes-no","label":"Does the above, schedule include- All persons in your service?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide yearly wages and loss amounts for contractors for past 3 years","type":"table","label":"State the total Wages paid and particulars of accidents to your contractors employees during the past three years. Year [Past 3 years from this date], Wages Paid, Amount of Loss","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Compliance and Insurance History","fields":[{"help":"Confirm compliance with safety and statutory regulations","type":"yes-no","label":"Do you comply with all statutory obligations, manufacturer’s recommendations and other safety regulations in conduct of the Business.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Confirm maintenance of accurate employee and wage records","type":"yes-no","label":"Do you maintain an accurate record of the Employees and Wages in respect of the Business in compliance with all statutory requirements.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide names of insurance companies if applicable","type":"text","label":"Are you at present insured or have you ever proposed for an insurance in respect of your liability to your employees? If so, please give the name of the Company or Companies.","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any proposal was declined","type":"yes-no","label":"Has any proposal for an insurance in respect of your liability to your employees or renewal thereof ever been declined or withdrawn? Declined","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if any proposal was withdrawn","type":"yes-no","label":"Has any proposal for an insurance in respect of your liability to your employees or renewal thereof ever been declined or withdrawn? Withdrawn","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Indicate if you have an Electronic Insurance Account","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if available","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":"Indicate if you want an EIA account created","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":"Provide email registered with insurance repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Note about address precedence","type":"text","label":"Your address details as mentioned in the EIA account shall override the address provided in this application for Insurance.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter bank account number for premium payment","type":"text","label":"Details as per premium cheque to be used for electronic fund transfer; Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank 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 cheque or demand draft number","type":"text","label":"Cheque / D.D#","options":[],"required":null,"pdf_field":""},{"help":"Enter name of bank branch cheque/DD is drawn on","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"Enter bank and branch name","type":"text","label":"Bank and Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction reference number for card payment","type":"text","label":"For Credit / Debit Card - Transaction Reference No","options":[],"required":null,"pdf_field":""},{"help":"Enter date of transaction","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC or MICR code of bank branch","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Enter amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Enter date of transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details (Applicable for individual customers)","fields":[{"help":"Enter full name of nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"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":"Enter nominee's present address","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Provide nominee's bank details","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage share of claim (total must not exceed 100%)","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Enter name of appointee if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee - Name of the Appointee","options":[],"required":null,"pdf_field":""},{"help":"Enter appointee's date of birth","type":"date","label":"Where Nominee is a minor, give details of Appointee - Date of Birth DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship of appointee to nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee - Relationship with the Nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Declarations and Information","fields":[{"help":"Indicate if associated with a PEP","type":"yes-no","label":"Are You or any of the proposed applicants or close relatives is/are associated to Politically Exposed Person (PEP)?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if you are a non-profit organization","type":"yes-no","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Sign or stamp the form","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"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":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"Agree to AML declaration","type":"checkbox","label":"AML Declaration","options":["I/We confirm premiums are paid from bonafide sources and understand the company’s rights under AML laws."],"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 authorized person","type":"signature","label":"Vernacular Declaration - 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 or thumb impression of proposer with disability","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD) - Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Declaration in case the proposer/policyholder is person with disability (PWD) - Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Declaration in case the proposer/policyholder is person with disability (PWD) - Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Employees Compensation Insurance policies","attachments":["Additional sheets if required for answers","Proof of Identity (POI) and Proof of Address (POA)","Cancelled cheque for electronic fund transfer","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["All statements and particulars provided are true and complete and form the basis of the contract.","The proposer agrees to inform the company of any material changes after submission.","Insurance contract is effective only upon company acceptance and receipt of premium.","The proposer undertakes to exercise all statutory and reasonable safety precautions for employees.","Consent is given to verify identity and address through official government portals.","Premiums are paid from bonafide sources and comply with anti-money laundering laws.","No rebates or inducements are allowed under the Insurance Act."],"dropped_labels":20},"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/5503-employees-compensation-insurance-proposal-form"}