{"id":5504,"title":"Extended Warranty Insurance Proposal Form & Questionnaire","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Extended_Warranty_Insurance_Individual_Proposal_Form_ZK_V2_24_25_12122024_ca05653a45.pdf","sha256":"e0e0592c178b0e585ec6b64d51008b3c363be39727f486ffd3e7e2d023acbf2a","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals to apply for Extended Warranty Insurance for their assets. The proposer (individual customer) fills it.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","Sum insured should represent the original purchase price of the item.","Policy issuance is at the sole discretion of the insurer and subject to underwriting policy.","Submission of proposal or payment does not oblige the insurer to issue a policy.","If proposal is not accepted, payment will be refunded without interest.","All policy and service communication will be sent in soft copy to the email provided unless physical copy is requested.","Use original documents for proofs and cancelled cheque for refund details.","Nominee details must be complete; provide appointee details if nominee is minor."],"title":"Extended Warranty Insurance Proposal Form & Questionnaire","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":"401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063, Maharashtra, India"},"purpose":"proposal","sections":[{"title":"Proposer / Owner's Details","fields":[{"help":"Enter your full name in block letters.","type":"text","label":"Proposer's Name*","options":[],"required":true,"pdf_field":""},{"help":"Provide your full permanent address.","type":"text","label":"Proposer's Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter your phone number.","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter your email address.","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Permanent address line 1.","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Permanent address line 2.","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to your permanent address.","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of permanent address.","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of permanent address.","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Country of permanent address.","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of permanent address.","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Select Yes if postal address is same as permanent address, else No.","type":"yes-no","label":"Is the Postal Address same as the Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Postal address line 1 if different.","type":"text","label":"If ‘No’, please provide below Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Postal address line 2 if different.","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to postal address if different.","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of postal address if different.","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of postal address if different.","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Postal address if different from permanent address.","type":"text","label":"Postal Address*","options":[],"required":false,"pdf_field":""},{"help":"Country of postal address if different.","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of postal address if different.","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes if you have GSTIN or Form 60 instead of PAN.","type":"yes-no","label":"GSTIN / Form 60 (only in case the customer does not have PAN No.)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter your PAN number.","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Enter your GSTIN if applicable.","type":"text","label":"GSTIN:","options":[],"required":false,"pdf_field":""},{"help":"Select your occupation.","type":"choice","label":"Occupation","options":["Salaried","Professionals","Student","Housewife","Retired","Others"],"required":false,"pdf_field":""},{"help":"Select your nationality.","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"Select your 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":false,"pdf_field":""},{"help":"Enter your CKYC number if available.","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Tick the documents you are submitting as proof of identity and address.","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":false,"pdf_field":""},{"help":"Enter bank name if asset is hypothecated.","type":"text","label":"Hypothecation Details: Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details and Payment Details","fields":[{"help":"Enter cheque or demand draft number if applicable.","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Enter amount drawn on cheque/DD.","type":"amount","label":"Drawn Amount","options":[],"required":false,"pdf_field":""},{"help":"Name on cheque/DD.","type":"text","label":"Drawn To","options":[],"required":false,"pdf_field":""},{"help":"Date of cheque/DD.","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code.","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Name of bank and branch.","type":"text","label":"Bank and Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction reference number.","type":"text","label":"For Credit/Debit Card: Transaction Reference No","options":[],"required":false,"pdf_field":""},{"help":"Date of card transaction.","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"IFSC or MICR code for refund account.","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Bank name for refund account.","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Name of account holder for refund.","type":"text","label":"Account Holder name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Questions","fields":[{"help":"Select Yes or No.","type":"yes-no","label":"Has any Company: a) Declined your Proposal?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if any above answer is Yes.","type":"text","label":"If yes in any of the above case, please provide details:","options":[],"required":false,"pdf_field":""},{"help":"Enter start and end date of insurance period.","type":"date","label":"Period of Insurance (after Expiry of the Manufacturer's Warranty Period on the Asset proposed for Insurance) From _________________ to _________________","options":[],"required":true,"pdf_field":""},{"help":"Provide any other relevant information.","type":"text","label":"Is there any other material information relevant to the acceptance of this proposal which must be known to the Company?","options":[],"required":false,"pdf_field":""},{"help":"Select if you want additional cover for Pick Up and Drop Services.","type":"yes-no","label":"Please specify any additional cover you wish to opt. for Pick Up and Drop Services","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter sum insured amount for additional cover.","type":"amount","label":"Sum Insured: `","options":[],"required":false,"pdf_field":""},{"help":"Enter deductible amount if any.","type":"amount","label":"Deductible Amount __________________","options":[],"required":false,"pdf_field":""},{"help":"Select if you have an Electronic Insurance Account.","type":"yes-no","label":"Do you have an EIA Account:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter your EIA number if applicable.","type":"text","label":"If Yes, please quote EIA Number:","options":[],"required":false,"pdf_field":""},{"help":"Enter name of insurance repository.","type":"text","label":"Please mention name of Insurance Repository:","options":[],"required":false,"pdf_field":""},{"help":"Select if you want the insurer to create an EIA account.","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":"Enter email registered with insurance repository.","type":"email","label":"Email id (Registered with Insurance Repository):","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Sign or provide thumb impression here.","type":"signature","label":"Signature / Thumb impression 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":""},{"help":"Tick if you qualify as HNI.","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":["Tick if applicable"],"required":false,"pdf_field":""},{"help":"Select if you or relatives are PEPs.","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":false,"pdf_field":""},{"help":"Select 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":false,"pdf_field":""},{"help":"Select type of organization if applicable.","type":"choice","label":"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"}],"deadlines":[],"applies_to":"Extended Warranty Insurance","attachments":["Proof of Identity (POI) and Proof of Address (POA) documents as ticked","Additional sheets if more space is needed for answers","Cancelled cheque for refund/claims bank details","Insurance Repository Application form if opting for EIA account creation"],"declarations":["The statements made in this Proposal Form are true, complete and form the basis of the insurance policy.","The insurer's liability starts only after acceptance of the proposal and receipt of premium.","The insurer may void the policy if any information is untrue, incorrect, or withheld.","All premiums are paid from bonafide sources and not from proceeds of crime.","Consent is given to verify identity/address through official registries for KYC.","The proposer may be classified as High Net Worth Individual only if declared.","The insurer is not liable if NEFT transactions fail.","The proposer confirms understanding of the policy terms and conditions.","Declarations by intermediary and agent that the policy features and terms were explained.","Declaration and authorization if proposer is a person with disability requiring assistance."],"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/5504-extended-warranty-insurance-proposal-form-and-questionnaire"}