{"id":5517,"title":"Health Premier Proposal Form (Edge)","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Health_Premier_Edge_GO_GREEN_Proposal_Form_ZK_26_27_v1_17032026_4a69317689.pdf","sha256":"148e32bb314ab7db4f47746b8eb40a1315a12d4125d911ce06ae8b84bc32c67c","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase the Health Premier Edge insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and coverage details for underwriting.","notes":["Fill the proposal form in BLOCK LETTERS.","All fields marked with * are mandatory.","Submission of this form does not guarantee policy issuance; acceptance is at insurer's discretion.","Attach additional sheets if required and indicate question number.","Online or credit card premium payment must be made by the policyholder; third party payments not allowed.","Use original documents for proof of identity and address.","Provide bank details for electronic fund transfer of claims and refunds.","The insurer is not liable if NEFT transactions fail.","No rebates or inducements are allowed as per Insurance Act 1938."],"title":"Health Premier Proposal Form (Edge)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details and Proposer's Information","fields":[{"help":"","type":"choice","label":"Individual / Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Select plan name","type":"text","label":"Plan Name*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Base Annual Sum Insured*","options":["5 lac","7.5 lac","10 lac","15 lac","20 lac"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Indicate if you want installment payment","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select frequency if installment option is Yes","type":"choice","label":"If yes, Installment Frequency*:","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Type of Cover*","options":[],"required":true,"pdf_field":""},{"help":"Date when coverage should start","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"First Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Last Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill if correspondence address differs","type":"text","label":"Correspondence Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of proposer","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Profession*","options":["Salaried","Professionals","Student","Housewife","Retired","Others","Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Others"],"required":true,"pdf_field":""},{"help":"Permanent Account Number for tax identification","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable documents","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [Tick (ü) whichever is applicable]","options":["PAN","Ration Card","Passport","Driving Licence","Voter ID Card"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Columns: Sr. No., Basic Covers, Cover Details","type":"table","label":"Basic Covers","options":[],"required":null,"pdf_field":""},{"help":"Columns: Sr. No., Cover Details, Yes/No choice","type":"table","label":"Would you like to opt for the following","options":[],"required":null,"pdf_field":""},{"help":"Zone I: Mumbai and Delhi NCR; Zone II: Kolkata, Hyderabad, Chennai, Pune, Bangalore, Gujarat; Zone III: Rest of India","type":"choice","label":"Please select the Zone:","options":["Zone I","Zone II","Zone III"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"Columns: Marital Status*, Name in Full*, Relation with the Proposer*, Date of Birth DD/MM/YYYY*, Gender*, Height (cm)*, Weight (kg)*, Occupation*","type":"table","label":"Insured Details","options":[],"required":true,"pdf_field":""},{"help":"If not created, visit https://healthid.ndhm.gov.in/ to create","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""},{"help":"If yes, provide Policy No.","type":"yes-no","label":"Zurich / Kotak Group Employees - Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide CRN and Employee ID","type":"yes-no","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Hospitalisation Information","fields":[{"help":"Columns: Insured 1 to Insured 6, with questions on health conditions, hospitalizations, medications, etc.","type":"table","label":"Section A: Medical and Hospitalisation Information","options":[],"required":null,"pdf_field":""},{"help":"Provide details on smoking, alcohol consumption, accidents, infections, allergies, HIV/AIDS, etc.","type":"text","label":"Section B: Lifestyle Information","options":[],"required":null,"pdf_field":""},{"help":"Columns: Period of Insurance, Insurance Company, Type of Policy, Ailment for which claim was made, Base Sum Insured, Claim amount paid/rejected, Year of claim, Others","type":"table","label":"Section C: Existing Health Insurance Details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any claims made previously","type":"text","label":"Section D: Details of claims","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Provide for claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Total share cannot exceed 100%","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name, Date of Birth, Relationship with Nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account and Payment Details","fields":[{"help":"","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"If yes, fill Insurance Repository Application form","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If paying by cheque or demand draft","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Premium amount","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Bank name","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":"","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Transaction Date","options":[],"required":false,"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":"Declarations and Signatures","fields":[{"help":"Sign or thumb impression","type":"signature","label":"Signature / Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary who explained the form","type":"signature","label":"Signature of Intermediary / Sales Person","options":[],"required":true,"pdf_field":""},{"help":"If proposer requires assistance in local language","type":"signature","label":"Vernacular Declaration Signature / Thumb impression of Proposer","options":[],"required":null,"pdf_field":""},{"help":"Signature of proposer and authorized representative","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":null,"pdf_field":""},{"help":"Agent declaration and signature","type":"signature","label":"Declaration for Agent","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Health Premier Edge health insurance policy proposal","attachments":["Additional sheets if space is insufficient to complete details","Proof of Identity (POI) and Proof of Address (POA) documents as applicable","Cancelled Cheque for bank account verification","Insurance Repository Application form if EIA account creation requested"],"declarations":["The information provided is true, complete and forms the basis of the insurance policy.","The policy will be effective only after full payment of premium and acceptance by the company.","Notify the company in writing of any change in occupation or health after proposal submission and before acceptance.","Consent to company seeking medical and other information for underwriting and claims.","Consent to share proposal and medical records with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy requested.","Consent to verify identity/address through government registries for KYC.","Consent to share medical records via ABHA number for underwriting and claims.","Declaration of High Net Worth Individual status if applicable.","Declaration that premiums are paid from bonafide sources and compliance with anti-money laundering laws.","Disclosure of association with Politically Exposed Persons if applicable.","Disclosure if proposer is a Non-Profit Organization if applicable."],"dropped_labels":3},"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/5517-health-premier-proposal-form-edge"}