{"id":5510,"title":"Group Health Care 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/Group_Health_Care_GO_GREEN_Proposal_Form_ZK_V1_25_26_11082025_b9f8c67506.pdf","sha256":"8672184e869dab7cfcc449f0b9f7ae29f64f41ef763bf979273f7ce39a5c1353","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by organizations or groups to apply for group health insurance coverage from Zurich Kotak General Insurance Company. It is filled by the proposer or group administrator.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if more space is needed, indicating question number.","Submission of the form or payment does not guarantee policy issuance.","Premium must be paid in full and on time for policy to be effective.","Use original documents where required.","Provide bank details for electronic fund transfer of payments and claims.","The total percentage share of claim among nominees cannot exceed 100%."],"title":"Group Health Care Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Information","fields":[{"help":"Full official name of the proposer organization","type":"text","label":"Name of the Proposer/ Group Administrator/ Bank/ Financial Institution (Organisation/ Institute/ Association)*","options":[],"required":true,"pdf_field":""},{"help":"Nature of business or activity of the proposer","type":"text","label":"Proposer’s Trade/ Business/ Activity*","options":[],"required":true,"pdf_field":""},{"help":"Registered office address line 1","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Registered office address line 2","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Nearest landmark to the registered office","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"City or district of the registered office","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"State of the registered office","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Full registered office address","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of the registered office","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Postal code of the registered office","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Select Yes if mailing address is same as registered office","type":"yes-no","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Mailing address if different from registered office","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Official email address of the proposer","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Goods and Services Tax Identification Number","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN*","options":[],"required":true,"pdf_field":""},{"help":"Central KYC Registry identifier if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":null,"pdf_field":""},{"help":"Indicate if proposer has existing policy with insurer","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Existing policy number if applicable","type":"text","label":"If Yes Policy Number","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy and Coverage Details","fields":[{"help":"Start and end date of the policy period","type":"date","label":"1. Policy Period From / To","options":[],"required":null,"pdf_field":""},{"help":"Specify categories of insured persons","type":"text","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, etc.)","options":[],"required":null,"pdf_field":""},{"help":"Specify relationships covered under the policy","type":"text","label":"4. Relationships Covered","options":[],"required":null,"pdf_field":""},{"help":"Select sum insured basis","type":"choice","label":"5. Sum Insured Basis (Individual Sum Insured / Family Floater Sum Insured)","options":["Individual Sum Insured","Family Floater Sum Insured"],"required":null,"pdf_field":""},{"help":"Select if premium payment in installments is desired","type":"yes-no","label":"6. Installment Option* (Yes / No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select installment frequency if applicable","type":"choice","label":"If ‘Yes’, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"Select one TPA for cashless claims","type":"choice","label":"Please select your choice of TPA (Third Party Administrator) to service your cashless claims.","options":["Family Health Plan Insurance TPA Ltd.","Paramount Health Services & Insurance TPA Pvt. Ltd.","Medi Assist Insurance TPA Pvt. Ltd."],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Unique membership or employee number","type":"text","label":"Membership ID/ Employee Number","options":[],"required":true,"pdf_field":""},{"help":"Category of the insured person","type":"text","label":"Category","options":[],"required":true,"pdf_field":""},{"help":"Full name of the insured person","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of the insured person","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"Gender of the insured person","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Relationship to the proposer or primary insured","type":"text","label":"Relationship with the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Job title or occupation","type":"text","label":"Designation/ Occupation","options":[],"required":true,"pdf_field":""},{"help":"Declare any pre-existing illnesses","type":"text","label":"Any existing illness","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Period of previous policy","type":"text","label":"Policy Period From – To","options":[],"required":null,"pdf_field":""},{"help":"Name of previous insurer","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Number of members covered under previous policy","type":"number","label":"Number of Members Covered","options":[],"required":null,"pdf_field":""},{"help":"Total premium paid for previous policy","type":"amount","label":"Total Premium (`)","options":[],"required":null,"pdf_field":""},{"help":"Total claims paid and outstanding under previous policy","type":"amount","label":"Total amount of claims (Paid + Outstanding) (`)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or demand draft number","type":"text","label":"Cheque / DD#","options":[],"required":null,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Bank on which cheque/DD is drawn","type":"text","label":"Drawn On","options":[],"required":null,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Bank name for payment","type":"text","label":"Bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Transaction reference number for card payment","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Date of card transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of the insured person","type":"text","label":"Insured Name*","options":[],"required":true,"pdf_field":""},{"help":"Name of the nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee to proposer","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of nominee","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Mobile number of nominee","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Email address of nominee","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Current address of nominee","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Permanent address of nominee","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Bank details for claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim for nominee","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Details of appointee if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee: Name, Date of Birth DD/MM/YYYY, Relationship with the Nominee, Name of the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details","fields":[{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank account holder","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Check if no bank account exists","type":"checkbox","label":"No existing Bank Account","options":[],"required":null,"pdf_field":""},{"help":"Check if cancelled cheque from other bank is submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized representative if proposer is person with disability","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":true,"pdf_field":""},{"help":"Declare if any applicant or close relative is 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":"Declare if proposer is 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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group Health Care insurance policies","attachments":["Additional sheets if more space is needed to answer questions","Cancelled Cheque (if applicable)"],"declarations":["The information provided is true, complete and accurate to the best of the proposer’s knowledge.","The policy will be issued only after acceptance by the company and full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent is given to the company to seek medical and insurance information for underwriting and claims.","Consent is given to share proposal and medical information with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","Consent is given to verify identity/address through government or regulatory portals for KYC.","All premiums are paid from bonafide sources and not from proceeds of crime as per AML regulations.","The insurance company may cancel the contract if found guilty under money laundering laws.","The insurance advisor confirms that the policy features and terms were explained to the proposer.","No rebates or inducements are allowed as per Insurance Act Section 41.","If proposer is a person with disability, an authorized representative may assist in completing the form."],"dropped_labels":9},"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/5510-group-health-care-proposal-form"}