{"id":5506,"title":"Fidelity Guarantee 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/Fidelity_Guarantee_Insurance_Proposal_Form_ZK_V2_24_25_12122024_6f9ce050c5.pdf","sha256":"3de48952606c4de823acda08ed7e13f11df312eb931f75cf4c75e076287e4b58","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or corporate proposers to apply for Fidelity Guarantee Insurance coverage by providing detailed information about themselves, their employees, and business practices.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","Attach additional sheets if more space is needed, indicating question number.","Information given will be treated in strict confidence.","Use original and valid documents for proof of identity and address.","Total nominee share percentage cannot exceed 100%.","Electronic Insurance Account (EIA) email ID is mandatory if EIA account exists or is to be created.","The insurer is not obliged to issue a policy upon submission of proposal or payment.","Policy issuance is subject to underwriting policy and receipt of premium in full and in time.","Policy and service communications will be sent in soft copy to the email provided unless physical copy is requested."],"title":"Fidelity Guarantee Insurance Proposal Form & Questionnaire","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Owner’s Details","fields":[{"help":"Enter full name of the proposer","type":"text","label":"Proposer’s 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 contact phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Enter city or district","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"Provide registered or permanent address","type":"text","label":"Registered Office Address / Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Tick 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":"Provide communication postal address if different","type":"text","label":"Communication (Postal) Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter GST Identification Number","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Provide nearest landmark to address","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter country","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Fill if proposer is an individual","type":"section","label":"For Individual customers, please share below details:","options":[],"required":null,"pdf_field":""},{"help":"Enter Permanent Account Number","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["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":"Tick applicable 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":"Fill if proposer is a corporate entity","type":"section","label":"For Corporate customers, please share below details:","options":[],"required":null,"pdf_field":""},{"help":"Enter corporate PAN","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Enter corporate GSTIN","type":"text","label":"GSTIN:","options":[],"required":null,"pdf_field":""},{"help":"Provide details of authorized signatory","type":"section","label":"Please share the below details for the Authorised Signatory:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of authorized signatory","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter designation","type":"text","label":"Designation:","options":[],"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 yes or no","type":"yes-no","label":"Have any losses been reported (whether insured or not) due to fraud or dishonesty of employees, partners or directors during the last five years? *","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If Yes, Please provide detail with date of loss, circumstances and amount.","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Has any Insurer in respect of the risk to which this proposal relates to, ever declined your proposal, refused renewal or cancelled your policy?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If Yes, please provide details.","options":[],"required":null,"pdf_field":""},{"help":"Enter paid up capital amount","type":"amount","label":"Paid up capital of firm","options":[],"required":null,"pdf_field":""},{"help":"Enter year or date of establishment","type":"date","label":"Established Since*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Cover Details and Employee Information","fields":[{"help":"Tick one option","type":"choice","label":"Which of the following type of cover your require","options":["Cover for named employees only (Please answer Question 2)","Cover entire workforce (Please answer Question 3)","Cover for select categories of employees only (Please answer Question 4)"],"required":true,"pdf_field":""},{"help":"Provide Name, Designation, Duties, Since when in service, Period of Insurance required","type":"table","label":"Cover named employees only","options":[],"required":null,"pdf_field":""},{"help":"Provide Category of employee, No. of Employees, Estimated Annual Wages, Staff with direct responsibility for money, stock, accounts or computer operations etc. (specify nature of work)","type":"table","label":"Cover for entire workforce","options":[],"required":null,"pdf_field":""},{"help":"Provide Category of employees, No. of Employees, Sum Insured, Total Remuneration, Employee Sum Insured","type":"table","label":"Cover for select categories of employees only","options":[],"required":null,"pdf_field":""},{"help":"Provide amounts and periods for money and stock","type":"section","label":"Please state the estimated maximum amount of money and / or stock which will be held by any employee at any one time and the period for the same?","options":[],"required":null,"pdf_field":""},{"help":"Describe reference system or practice","type":"text","label":"Is there a system to obtain references from previous Employers? If not, specify practice followed.","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable extensions and provide details if needed","type":"checkbox","label":"Please confirm whether Policy extension is required for:","options":["Coverage of Foreign Exchange","Additional Expenses for substantiating the claim","Coverage for contractual employee (Please provide details of such employee as per question 2, 3,4)*","Retroactive period, if yes please provide from when?"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you in the past ever had an occasion to question the honesty or integrity or conduct of any person proposed for guarantee? If yes, please provide details.","options":[],"required":null,"pdf_field":""},{"help":"Describe bank account operation system and precautions","type":"text","label":"System of operation of Bank account and precautions taken","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Whether such payments / withdrawals are authorized by a senior employee and substantiated with supporting documents?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide frequency and details","type":"text","label":"How often the cash book is balanced, the entries checked with vouchers and Bank’s pass book and with counterfoils of receipt books?","options":[],"required":null,"pdf_field":""},{"help":"Provide frequency","type":"text","label":"How often are the Proposer’s books balanced?","options":[],"required":null,"pdf_field":""},{"help":"Provide frequency and responsible person","type":"text","label":"How often and by whom is the stock verification done?","options":[],"required":null,"pdf_field":""},{"help":"Describe system for dues collection","type":"text","label":"What is the system for collecting outstanding dues?","options":[],"required":null,"pdf_field":""},{"help":"Provide audit details","type":"text","label":"What is the extent and frequency of audit?","options":[],"required":null,"pdf_field":""},{"help":"Provide frequency","type":"text","label":"How often are the employees required to account for money?","options":[],"required":null,"pdf_field":""},{"help":"Describe independent accounting system","type":"text","label":"Please provide details of independent system in existence to ensure that all money/stock received by employees are accounted for?","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","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter present address","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Provide bank name and account details","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage share (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":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":null,"pdf_field":""},{"help":"Enter name of appointee","type":"text","label":"Name of the Appointee","options":[],"required":null,"pdf_field":""},{"help":"Enter appointee date of birth","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the Nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment and Electronic Insurance Account Details","fields":[{"help":"Tick yes or no","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 insurance repository name","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":null,"pdf_field":""},{"help":"Tick 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 id registered with repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Note only","type":"note","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":""},{"help":"Tick if cancelled cheque submitted","type":"checkbox","label":"Details as per premium cheque to be used for electronic fund transfer; Cancelled cheque submitted of other bank","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"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 name","type":"text","label":"Account Holder name","options":[],"required":null,"pdf_field":""},{"help":"Provide payment details","type":"section","label":"PAYMENT DETAILS","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 payee name","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":"Provide card payment details","type":"section","label":"For Credit / Debit Card","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction reference number","type":"text","label":"Transaction Reference No","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC or MICR code","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 transaction date","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account details for refund/claims","type":"section","label":"BANK ACCOUNT DETAILS","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or affix stamp","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Sign or affix stamp","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Sign or affix stamp","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 or thumb impression of proposer and authorized representative","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Fidelity Guarantee Insurance","attachments":["Additional sheets if space is insufficient to complete details","Proof of Identity and Proof of Address documents","Cancelled cheque for electronic fund transfer","Insurance Repository Application form (if EIA account to be created)"],"declarations":["Statements made in this Proposal Form and Questionnaire are true, complete and form the basis of the policy.","The insurer’s liability commences only after acceptance of the proposal and receipt of premium.","The policy shall be voidable if any material information is untrue, incorrect, incomplete or withheld.","The proposer consents to verification of identity/address through government or regulatory portals.","Premiums are paid from bonafide sources and not from proceeds of crime; insurer may cancel policy if otherwise.","The proposer declares if they qualify as a High Net Worth Individual (HNI) with net worth of ₹50 crore or more.","No person shall offer or accept rebates on premiums except as allowed by insurer’s published prospectuses.","The proposer authorizes an appointed representative to assist if they have a disability."],"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/5506-fidelity-guarantee-insurance-proposal-form-and-questionnaire"}