{"id":5514,"title":"Group Secure Shield - Non 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_NCL_Proposal_Form_ZK_V1_25_26_11082025_011c32e477.pdf","sha256":"72bb1e1f39c26c97327cd8598e0834127964e16ceb13024fddf7f5b6b3874aa1","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer such as a group administrator, bank, financial institution, or organization to apply for the Group Secure Shield insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide details about the group, coverage, nominees, insured persons, and payment.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if more space is needed, indicating question numbers.","Information provided will be treated in strict confidence.","Submission of the proposal 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.","Electronic fund transfer details must be provided for payments and claims.","Consent is required for ASBA facility to block premium from bank account.","Insurance is a subject matter of solicitation."],"title":"Group Secure Shield - Non 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 of the proposer","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 the authorised signatory","type":"text","label":"Name:","options":[],"required":false,"pdf_field":""},{"help":"Designation of the authorised signatory","type":"text","label":"Designation:","options":[],"required":false,"pdf_field":""},{"help":"CKYC number of authorised signatory","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":false,"pdf_field":""},{"help":"Full 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","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 the 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":"choice","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":"Group Secure Shield Number","type":"text","label":"GSSN","options":[],"required":false,"pdf_field":""},{"help":"Select premium payment frequency","type":"choice","label":"Installment Frequency*","options":["Monthly","Quarterly","Half yearly","Annually"],"required":true,"pdf_field":""},{"help":"Unclear context, possibly related to installment option","type":"choice","label":"Yes No If yes,","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify installment option","type":"text","label":"3. Installment Option*","options":[],"required":true,"pdf_field":""},{"help":"Number of persons in category 3","type":"number","label":"c. Cat 3:","options":[],"required":false,"pdf_field":""},{"help":"Number of persons in category 4","type":"number","label":"d. Cat 4:","options":[],"required":false,"pdf_field":""},{"help":"Number of persons in category 5","type":"number","label":"e. Cat 5:","options":[],"required":false,"pdf_field":""},{"help":"Specify policy start and end dates","type":"section","label":"1. Policy Period:","options":[],"required":false,"pdf_field":""},{"help":"Policy start date","type":"date","label":"From:","options":[],"required":false,"pdf_field":""},{"help":"Policy end date","type":"date","label":"To: Midnight of","options":[],"required":false,"pdf_field":""},{"help":"Total number of persons to be insured","type":"number","label":"2. Number of Persons to be insured","options":[],"required":false,"pdf_field":""},{"help":"List categories of insured persons","type":"section","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, Trust etc.)","options":[],"required":false,"pdf_field":""},{"help":"Number of persons in category 1","type":"number","label":"a. Cat 1:","options":[],"required":false,"pdf_field":""},{"help":"Number of persons in category 2","type":"number","label":"b. Cat 2:","options":[],"required":false,"pdf_field":""},{"help":"Details of coverage options and sums insured","type":"section","label":"COVERAGE DETAILS (*)","options":[],"required":true,"pdf_field":""},{"help":"Quote number for the proposal","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Branch code of insurer","type":"text","label":"Branch Code","options":[],"required":false,"pdf_field":""},{"help":"Date of the 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 of intermediary","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 for intermediary","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":"Previous Policy Details","fields":[{"help":"Provide start and end dates of previous policies","type":"text","label":"Policy Period From - To","options":[],"required":false,"pdf_field":""},{"help":"Name of previous insurer","type":"text","label":"Name of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Policy number","options":[],"required":false,"pdf_field":""},{"help":"Number of members covered under previous policy","type":"number","label":"Number of members covered","options":[],"required":false,"pdf_field":""},{"help":"Total premium paid for previous policy","type":"amount","label":"Total premium (`)","options":[],"required":false,"pdf_field":""},{"help":"Total claims paid and outstanding under previous policy","type":"amount","label":"Total amount of claims (Paid + Outstanding) (Rs.)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Details","fields":[{"help":"Serial number for each cover option","type":"number","label":"Sr. No.","options":[],"required":false,"pdf_field":""},{"help":"Select the cover options you want","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)"],"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 if survival period of 30 days is opted","type":"yes-no","label":"Survival Period Opted For","options":["Yes – 30 days","No"],"required":false,"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 between nominee and 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 of nominee 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":"Provide appointee details if nominee is minor","type":"section","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""},{"help":"Name of appointee for minor nominee","type":"text","label":"Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Date of birth of appointee","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Relationship of appointee with nominee","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""},{"help":"Name of nominee related to appointee","type":"text","label":"Name of the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Membership or employee number of insured","type":"text","label":"Membership ID/ Employee Number","options":[],"required":true,"pdf_field":""},{"help":"Category of 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 of insured person to proposer","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":"Sum insured for the person","type":"amount","label":"Sum Insured","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":"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 receipt","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 bank account exists","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Tick if cancelled cheque from other bank is submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"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":"Signature or thumb impression of proposer","type":"signature","label":"Signature of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Signature and stamp of insurance advisor or intermediary","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 of authorized representative if proposer is person with disability","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":false,"pdf_field":""},{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Declare if any applicant or close relative is a PEP","type":"choice","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":"choice","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select type of organization if applicable","type":"choice","label":"In case of entity, Type of Organisation making the payment:","options":["Limited Company","International Organisation","Trust","Partnership","Section 25 Company","Non-Government Organisation (NGO)","Society","Others","Government Organisation","Co-operatives"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group Secure Shield insurance policy proposals","attachments":["Additional sheets if more space is needed to answer questions","Cancelled Cheque (if applicable)"],"declarations":["The proposer declares all information 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.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes sharing of proposal and medical information with government and regulatory authorities.","Policy and service communications will be sent by email unless physical copy is requested.","The proposer consents to KYC verification through specified government portals.","All premiums are paid from legitimate sources and not from proceeds of crime; insurer may cancel policy if otherwise.","The insurance advisor declares that policy features and terms were explained to the proposer.","No rebates or inducements are allowed under the Insurance Act 1938.","If proposer is a person with disability, they may authorize a representative to assist in completing the form.","The proposer confirms understanding of the proposal form contents in their language."],"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/5514-group-secure-shield-non-credit-linked-proposal-form"}