{"id":5513,"title":"Group Secure Shield - Credit Linked 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_Secure_Shield_CL_Proposal_Form_ZK_V1_25_26_11082025_97f8b35691.pdf","sha256":"ccafe7e22fa46e4587a6c4c39cd8dee041bd79ba608aec67c385d2ab1a0c4a03","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer such as a group administrator, bank, or financial institution to apply for the Group Secure Shield insurance policy. The proposer fills it to provide details about the group, insured persons, coverage options, and payment.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if more space is needed and indicate question number.","Information given will be treated in strict confidence.","Insurance is a subject matter of solicitation.","Submission of proposal or payment does not oblige the company to issue a policy.","Policy is subject to underwriting and receipt of premium in full and in time.","If proposal is not accepted, payment will be refunded without interest."],"title":"Group Secure Shield - Credit Linked Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Information","fields":[{"help":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide policy number if existing policy is held","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Pre-existing waiting period:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if any permanent exclusions apply","type":"text","label":"Permanent Exclusion","options":[],"required":false,"pdf_field":""},{"help":"","type":"section","label":"Please share the below details for the Authorised Signatory:","options":[],"required":false,"pdf_field":""},{"help":"Name of authorised signatory","type":"text","label":"Name:","options":[],"required":false,"pdf_field":""},{"help":"Designation of authorised signatory","type":"text","label":"Designation:","options":[],"required":false,"pdf_field":""},{"help":"For authorised signatory","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Full name of the proposer entity","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","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":false,"pdf_field":""},{"help":"Registered office address line 2","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to registered office","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of registered office","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of registered office","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Full registered office address","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of registered office","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of registered office","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill mailing address if different","type":"section","label":"If ‘No’, please provide below","options":[],"required":false,"pdf_field":""},{"help":"Mailing address line 1","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Mailing address line 2","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Nearest landmark to mailing address","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"City or district of mailing address","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"State of mailing address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Full mailing address","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of mailing address","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Postal code of mailing address","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Email address of 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":false,"pdf_field":""},{"help":"","type":"text","label":"GSSC","options":[],"required":false,"pdf_field":""},{"help":"Quote number for the proposal","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Branch code of proposer or intermediary","type":"text","label":"Branch Code","options":[],"required":false,"pdf_field":""},{"help":"Date of quote","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"Code of sales manager","type":"text","label":"Sales Manager Code","options":[],"required":false,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary Code","options":[],"required":false,"pdf_field":""},{"help":"Service relationship manager code","type":"text","label":"Intermediary Service RM","options":[],"required":false,"pdf_field":""},{"help":"Branch code of intermediary","type":"text","label":"Intermediary Branch code","options":[],"required":false,"pdf_field":""},{"help":"Business vertical of intermediary","type":"text","label":"Intermediary business vertical","options":[],"required":false,"pdf_field":""},{"help":"Client reference number","type":"text","label":"Intermediary Client Ref. No.","options":[],"required":false,"pdf_field":""},{"help":"Sales person name or code","type":"text","label":"SP Name/Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Start date of policy period","type":"date","label":"Policy Period: From:","options":[],"required":true,"pdf_field":""},{"help":"End date of policy period","type":"date","label":"To: Midnight of","options":[],"required":true,"pdf_field":""},{"help":"Select how often installments are paid","type":"choice","label":"Installment Frequency*","options":["Monthly","Quarterly","Half yearly","Annually"],"required":true,"pdf_field":""},{"help":"Choose sum insured basis","type":"choice","label":"Sum Insured Basis","options":["Fixed Sum Insured Basis","Reducing Sum Insured Basis"],"required":false,"pdf_field":""},{"help":"If yes, specify details","type":"yes-no","label":"Yes","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Additional details if yes","type":"text","label":"If yes,","options":[],"required":false,"pdf_field":""},{"help":"Specify installment option","type":"text","label":"Installment Option*","options":[],"required":true,"pdf_field":""},{"help":"Duration of policy","type":"text","label":"Policy Tenure","options":[],"required":false,"pdf_field":""},{"help":"Number of persons covered","type":"number","label":"No.of Persons to be insured","options":[],"required":false,"pdf_field":""},{"help":"Type of credit linked to policy","type":"text","label":"Type of credit","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Details","fields":[{"help":"Tick the covers you want to opt for","type":"checkbox","label":"Covers Opted","options":["Section I: Critical Illness Benefit","Section II: Personal Accident Benefit","Child Education Benefit (Can be opted for only if Personal Accident Benefit is taken)","Section III: Loss of Job Benefit (due to illness / accident)"],"required":false,"pdf_field":""},{"help":"Sum insured amount for each cover","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Select number of critical illnesses covered","type":"choice","label":"No of Critical Illnesses","options":["9","12","15","18","34"],"required":false,"pdf_field":""},{"help":"Select survival period option","type":"yes-no","label":"Survival Period Opted For","options":["Yes – 30 days","No"],"required":false,"pdf_field":""},{"help":"Indicate if pre-existing waiting period applies","type":"yes-no","label":"Pre-existing waiting period","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify any permanent exclusions","type":"text","label":"Permanent Exclusion","options":[],"required":false,"pdf_field":""},{"help":"Applicable for salaried persons only","type":"yes-no","label":"Section III: Loss of Job Benefit (due to illness / accident) (*)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Maximum number of EMIs for loss of job benefit","type":"choice","label":"Maximum No of EMIs opted","options":["3","6"],"required":false,"pdf_field":""},{"help":"Fill details for each nominee: Insured Name*, Nominee Name*, Relationship with Proposer*, Nominee Date of Birth (DD/MM/YYYY)*, Nominee Mobile Number, Nominee Email ID, Nominee Present Address, Nominee Permanent Address, Nominee Bank Name and Account Details, % of claim share* (total share must not exceed 100%). If nominee is minor, provide appointee details: Name, Date of Birth, Relationship with Nominee, Name of Nominee.","type":"table","label":"Nominee Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Provide policy period for past 3 policy periods or less","type":"text","label":"Policy Period From - To","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer for previous policies","type":"text","label":"Name of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number of previous policies","type":"text","label":"Policy number","options":[],"required":false,"pdf_field":""},{"help":"Number of members covered under previous policies","type":"number","label":"Number of members covered","options":[],"required":false,"pdf_field":""},{"help":"Total premium paid for previous policies","type":"amount","label":"Total premium (`)","options":[],"required":false,"pdf_field":""},{"help":"Total claims paid and outstanding for previous policies","type":"amount","label":"Total amount of claims (Paid + Outstanding) (`)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or demand draft number","type":"text","label":"Cheque / DD#","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Bank on which cheque/DD is drawn","type":"text","label":"Drawn On","options":[],"required":false,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Branch of bank","type":"text","label":"Bank Branch","options":[],"required":false,"pdf_field":""},{"help":"Transaction reference number for card payment","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":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Signature of company or intermediary official","type":"signature","label":"Signature of Zurich Kotak General Insurance Company (India) Limited / Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of official or intermediary","type":"text","label":"Zurich Kotak General Insurance Company (India) Limited Official/Intermediary Name:","options":[],"required":false,"pdf_field":""},{"help":"Time of receipt","type":"text","label":"Time HHMM","options":[],"required":false,"pdf_field":""},{"help":"Place of receipt","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details for Electronic Fund Transfer","fields":[{"help":"Bank account number for EFT","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","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 account holder","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Tick if no existing bank account","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Tick if cancelled cheque from other bank submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"Sign to declare all information is true and consent to terms","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":""},{"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"},{"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 stamp","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 of Person with Disability (PWD)","fields":[{"help":"Signature of authorized representative if proposer is PWD","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":false,"pdf_field":""},{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Vernacular Declaration","fields":[{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary/Sales Person*","options":[],"required":false,"pdf_field":""},{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":false,"pdf_field":""}],"filled_by":"agent and proposer"}],"deadlines":[],"applies_to":"Group Secure Shield - Credit Linked insurance policy proposal","attachments":["Additional sheets if more space is needed to answer questions","Cancelled Cheque for bank account details (if applicable)"],"declarations":["The proposer declares that all information provided is true and complete to the best of their 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.","The company may seek medical and other information for underwriting and claims settlement.","The company may share proposal and medical information with government or regulatory authorities.","Policy and service communications will be sent by email unless physical copies are requested.","Consent is given to verify identity/address through government portals for KYC.","All premiums are paid from bonafide sources and not from proceeds of crime under anti-money laundering laws.","The agent declares that the policy features and terms have been explained to the proposer.","No rebates or inducements are allowed under the Insurance Act.","If proposer is a person with disability, an authorized representative may assist in completing the form."],"dropped_labels":2},"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/5513-group-secure-shield-credit-linked-proposal-form"}