{"id":5511,"title":"Group Health Care - Micro 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/Group_Health_Care_Micro_Insurance_Proposal_Form_ZK_V1_25_26_11082025_a4a32f405d.pdf","sha256":"11d5c2d158a9ba39a9b49259b97ddae92209d8d1da08452715f87190cd61a4e1","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by organizations or groups to apply for group health insurance coverage under the Micro Insurance scheme. It is filled by the proposer such as a group administrator, bank, financial institution, or association.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","Original premium payment instruments should be in favor of Zurich Kotak General Insurance Company (India) Limited.","Bank details are required for electronic fund transfer of payments and claims.","The company may reject the proposal or policy if premium is not received in full and on time.","Use the email provided for all regulatory and policy servicing communications unless physical copy is requested."],"title":"Group Health Care - Micro Insurance Proposal Form","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’s Information","fields":[{"help":"Full legal 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":"Primary address line","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Secondary address line","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark for address clarity","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"City or district of the proposer","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"State of the proposer","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Registered office address of the proposer","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of the proposer","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Postal code","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 telephone 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 number 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":"choice","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 policy period","type":"date","label":"1. Policy Period From / To","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","options":["Individual Sum Insured","Family Floater Sum Insured"],"required":null,"pdf_field":""},{"help":"Choose if premium payment in installments is desired","type":"yes-no","label":"6. Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select installment frequency","type":"choice","label":"If ‘Yes’, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"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 insured person","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of insured person","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"Gender of insured person","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Relationship to 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 illness","type":"text","label":"Any existing illness","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Previous policy period","type":"date","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","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":"Card transaction reference number","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 insured person","type":"text","label":"Insured Name*","options":[],"required":true,"pdf_field":""},{"help":"Name of 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":null,"pdf_field":""},{"help":"Email address of nominee","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"Current address of nominee","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"Permanent address of nominee","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Bank details for nominee","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details for Electronic Fund Transfer","fields":[{"help":"Bank account number for payments","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Name of 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 account holder","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Tick if no bank account exists","type":"checkbox","label":"No existing Bank Account","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration for Agent","fields":[{"help":"Agent's signature and 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":"Proposer's signature or thumb impression","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Declaration in case Proposer/Policyholder is Person with Disability (PWD)","fields":[{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Vernacular Declaration","fields":[{"help":"Signature of intermediary","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":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary and proposer"},{"title":"Additional Declarations","fields":[{"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 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 - Micro Insurance policies","attachments":["Additional sheets if more space is required to answer any question","Cancelled Cheque for bank account verification"],"declarations":["The proposer declares that all information provided is true, complete and accurate to the best of their knowledge.","The policy will be issued only after acceptance of the proposal and full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent is given to the insurer to seek medical and other information for underwriting and claims.","Consent is given to share proposal and medical information with 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.","All premiums are paid from legitimate sources and not from proceeds of crime.","Agent declares that policy features and terms have been explained to the proposer.","Prohibition of rebates under Section 41 of Insurance Act is acknowledged.","If proposer is a person with disability, authorized representative may assist in form completion."],"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/5511-group-health-care-micro-insurance-proposal-form"}