{"id":5505,"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_Group_Proposal_Form_ZK_V2_24_25_12122024_8f279d7e1d.pdf","sha256":"fb6b96fe9d2a69e94165e3f35d0acf27bc02e50ab7e9daaef050329983fdc059","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by organizations or groups applying for Extended Warranty Insurance coverage. The proposer or group administrator fills it to provide details about their business, products, and warranty requirements.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","All information will be treated in strict confidence.","Policy issuance is at the sole discretion of the company.","Policy and service communications will be sent via email unless physical copy is requested.","Use original documents for attachments where applicable."],"title":"Extended Warranty Insurance Proposal Form & Questionnaire","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Owner's Details","fields":[{"help":"Enter the full registered name of the proposer or group administrator","type":"text","label":"Name of the Proposer/ Group Administrator/ Master Policy holder (Organisation/ Institute/ Association) * (Full Registered Name)","options":[],"required":true,"pdf_field":""},{"help":"Describe the trade or business of the proposer","type":"text","label":"Proposer's Trade or Business*","options":[],"required":true,"pdf_field":""},{"help":"Enter number of years the business has been operating","type":"number","label":"No of Years in Business","options":[],"required":false,"pdf_field":""},{"help":"Enter a contact phone number","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter an email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Enter nearest landmark","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"Enter city or district","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"Enter registered office address","type":"text","label":"Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is the Postal Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill postal address details if different","type":"group","label":"If ‘No’, please provide below","fields":[{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Enter postal address","type":"text","label":"Postal Address*","options":[],"required":true,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Enter GSTIN number","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter existing policy number if applicable","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""},{"help":"Provide corporate PAN and GSTIN","type":"group","label":"For Corporate customers, please share below details:","fields":[{"help":"Enter corporate PAN","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Enter corporate GSTIN","type":"text","label":"GSTIN:","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Provide details of authorized signatory","type":"group","label":"Please share the below details for the Authorised Signatory:","fields":[{"help":"Enter name of authorized signatory","type":"text","label":"Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter designation","type":"text","label":"Designation:","options":[],"required":false,"pdf_field":""},{"help":"Enter CKYC number","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for hypothecation","type":"text","label":"Hypothecation Details: Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Product Details","fields":[{"help":"Describe the products to be insured","type":"text","label":"Description of Products","options":[],"required":true,"pdf_field":""},{"help":"Attach product catalogues","type":"attachment","label":"Please provide products catalogues","options":[],"required":false,"pdf_field":""},{"help":"Select type of usage","type":"choice","label":"Type of Usage","options":["Private","Commercial"],"required":true,"pdf_field":""},{"help":"Specify product type","type":"text","label":"Type of Product to be insured","options":[],"required":true,"pdf_field":""},{"help":"Select if program is mandatory or voluntary","type":"choice","label":"Is the EW program mandatory or voluntary?","options":["Mandatory","Voluntary"],"required":true,"pdf_field":""},{"help":"Provide warranty wording and duration","type":"text","label":"Please provide specimen wording of the manufacturer’s warranty along with the duration","options":[],"required":true,"pdf_field":""},{"help":"Enter number of existing dealers","type":"number","label":"No of existing dealers","options":[],"required":false,"pdf_field":""},{"help":"Provide details of authorized repairers and outlets","type":"text","label":"Who is authorized to repair and number of authorized repair outlets","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Can the authorized repair outlet do warranty repairs?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide comments on limits if applicable","type":"text","label":"If Yes, comment of limits","options":[],"required":false,"pdf_field":""},{"help":"List repairable and replaceable parts","type":"text","label":"Under the original Manufacturer’s warranty, please list parts that are repairable and parts that are exchanged for new","options":[],"required":false,"pdf_field":""},{"help":"Select coverage type","type":"choice","label":"Mirror manufacturer’s warranty or selective parts coverage only?","options":["Mirror manufacturer’s warranty","Selective parts coverage only"],"required":false,"pdf_field":""},{"help":"List selective parts covered","type":"text","label":"If coverage is for selective parts, provide list","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Cover Details","fields":[{"help":"Specify additional cover options","type":"text","label":"Please specify any additional cover you wish to opt. for","options":[],"required":false,"pdf_field":""},{"help":"Select if pick up and drop services are required","type":"choice","label":"Pick Up and Drop Services","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured: `","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Supportive Information","fields":[{"help":"Select Yes or No","type":"choice","label":"Has product(s) ever been subject to manufacturer's recall for modification?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify warranty extension required","type":"text","label":"What extension is required to manufacturer's warranty period?","options":[],"required":false,"pdf_field":""},{"help":"Fill table with model type, units sold, and selling price for each year","type":"table","label":"No of units sold and selling price per unit of products by model for past 3 years, projected sales in the current year and the following 2 years","options":[],"required":false,"pdf_field":""},{"help":"Provide price list and labour cost by manufacturing year and model year","type":"table","label":"Major Components /Parts price list and Labour cost charged for the past 3 years, current year and the estimated cost for the following 2 years for which EW insurance is required","options":[],"required":false,"pdf_field":""},{"help":"Provide estimated failure rate as number of models with claims divided by total models sold","type":"text","label":"Estimated failure rate during the requested EW period","options":[],"required":false,"pdf_field":""},{"help":"Attach original manufacturer's warranty wordings, listing of models, original warranty booklet, and maintenance system details","type":"text","label":"Please provide the following information:","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional relevant information","type":"text","label":"Please provide any information, which you think, might be relevant to the proposed Extended Warranty Program.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Select Yes or No","type":"choice","label":"Do you have an EIA Account:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter 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 Yes or No","type":"choice","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":"Acknowledgement and Payment Details","fields":[{"help":"Enter name of person making payment","type":"text","label":"Received from Ms./Mrs./Mr.","options":[],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"a sum of Rs.","options":[],"required":false,"pdf_field":""},{"help":"Specify payment mode","type":"text","label":"Through Cheque/DD","options":[],"required":false,"pdf_field":""},{"help":"Signature of company official or intermediary","type":"signature","label":"Signature of Zurich Kotak General Insurance Company (India) Limited Official / Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Date of acknowledgement","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Time of acknowledgement","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Place of acknowledgement","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Provide payment mode and details","type":"group","label":"Payment Details","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Enter amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":false,"pdf_field":""},{"help":"Enter payee name","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":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank and branch name","type":"text","label":"Bank and Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Provide card transaction details","type":"group","label":"For Credit/Debit Card:","fields":[{"help":"Enter transaction reference number","type":"text","label":"Transaction Reference No:","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Transaction Date:","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Provide bank details for electronic fund transfer","type":"group","label":"Refund / Claims Detail","fields":[{"help":"Enter bank account number","type":"text","label":"Account Number:","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code:","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter account holder name","type":"text","label":"Account Holder name:","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and insurer"},{"title":"Previous Insurance Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Has there previously been an EW insurance program?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide insurer, duration, and loss ratio","type":"group","label":"If Yes, please provide","fields":[{"help":"Enter insurer name","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Enter duration of extended warranty","type":"text","label":"Duration of EW","options":[],"required":false,"pdf_field":""},{"help":"Enter loss ratio","type":"text","label":"Loss Ratio","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Answer Yes or No for each question","type":"group","label":"Has any insurer","fields":[{"help":"Select Yes or No","type":"choice","label":"Declined your Proposal?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Cancelled or refused to renew your Policy?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Accepted your Proposal on special terms and condition?","options":["Yes","No"],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""},{"help":"Provide details if any insurer declined, cancelled, or accepted on special terms","type":"text","label":"If yes in any of the above case, please provide details:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details (Applicable for individual customers)","fields":[{"help":"Enter nominee's full name","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship with 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":false,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's bank name and account details","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"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":"Provide appointee details if nominee is minor","type":"group","label":"Where Nominee is a minor, give details of Appointee","fields":[{"help":"Enter appointee name","type":"text","label":"Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee date of birth","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Enter relationship with nominee","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Statutory Warnings","fields":[{"help":"Sign or affix thumb impression","type":"signature","label":"Signature / Stamp of the Proposer*","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":""},{"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":"Signature and stamp of insurance advisor or authorized 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/thumb impression of proposer and authorized representative if applicable","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Extended Warranty Insurance for groups","attachments":["products catalogues","specimen wording of the manufacturer’s warranty","original Manufacturer's warranty wordings","listing of Models to be included in the proposed Extended Warranty Program","original Warranty Booklet","cancelled cheque for refund/claims detail","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["The statements made in this proposal form are true, complete, and form the basis of the insurance policy.","The company’s liability starts only after acceptance of the proposal and receipt of premium.","The policy is voidable if any material information is untrue, incorrect, or withheld.","Consent is given to verify identity/address through government portals for KYC.","Premiums are paid from bonafide sources and not from proceeds of crime.","No rebates are allowed as per Section 41 of Insurance Act 1938.","The proposer confirms understanding of the policy terms and conditions."],"dropped_labels":1},"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/5505-extended-warranty-insurance-proposal-form-and-questionnaire"}