{"id":5518,"title":"Group Smart Cash - 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_Smart_Cash_Micro_Insurance_Proposal_Form_ZK_V1_25_26_11082025_31c5de9c52.pdf","sha256":"39e75f4cc7f7fcba4266f0e83b8a9a247ba3113f114ee1adce0cd4a4831b80f8","pages":5,"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 Group Smart Cash - Micro Insurance coverage for a group of insured persons.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if more space is needed and indicate question numbers.","Information provided will be treated in strict confidence.","The issuance of this form does not mean acceptance of the proposal.","Policy becomes effective only after acceptance and premium receipt.","Use original documents and accurate information to avoid policy voidance.","Electronic fund transfer is the preferred mode for payments and claims.","The form includes statutory warnings about prohibition of rebates."],"title":"Group Smart Cash - Micro Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer's Information","fields":[{"help":"Enter the full name of the proposer or group administrator","type":"text","label":"Name of the Proposer/ Group Administrator/ Bank/ Financial Institution (Organisation/ Institute/ Association)*","options":[],"required":true,"pdf_field":""},{"help":"Describe the trade, business or activity of the proposer","type":"text","label":"Proposer’s Trade/ Business/ Activity*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"","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":"","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 or No","type":"yes-no","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if mailing address differs from registered office","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Enter contact number","type":"phone","label":"Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile 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":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide existing policy number if applicable","type":"text","label":"If Yes Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Select preferred installment frequency","type":"choice","label":"Installment Option*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"Define family members covered if applicable","type":"text","label":"Family Definition","options":[],"required":null,"pdf_field":""},{"help":"Specify relationships covered under policy","type":"text","label":"Relationships Covered","options":[],"required":null,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"text","label":"Type of Credit #","options":[],"required":null,"pdf_field":""},{"help":"List categories of insured persons","type":"text","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, etc.)","options":["Cat 1","Cat 2","Cat 3","Cat 4","Cat 5"],"required":null,"pdf_field":""},{"help":"Start date of policy period (DD/MM/YYYY)","type":"date","label":"Policy Period From:","options":[],"required":true,"pdf_field":""},{"help":"Select policy category","type":"choice","label":"Policy Category: Individual/Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Enter total number of insured persons","type":"number","label":"Number of Persons to be insured","options":[],"required":true,"pdf_field":""},{"help":"Enter quote number","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Branch code if applicable","type":"text","label":"Branch Code","options":[],"required":null,"pdf_field":""},{"help":"Date of quote (DD/MM/YYYY)","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"Code of sales manager","type":"text","label":"Sales Manager Code","options":[],"required":null,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"Service relationship manager","type":"text","label":"Intermediary Service RM","options":[],"required":null,"pdf_field":""},{"help":"Branch code of intermediary","type":"text","label":"Intermediary Branch code","options":[],"required":null,"pdf_field":""},{"help":"Business vertical of intermediary","type":"text","label":"Intermediary business vertical","options":[],"required":null,"pdf_field":""},{"help":"Client reference number","type":"text","label":"Intermediary Client Ref. No.","options":[],"required":null,"pdf_field":""},{"help":"Sales person name or code","type":"text","label":"SP Name/Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Benefit Details","fields":[{"help":"Enter daily cash amount in rupees","type":"amount","label":"Hospital Daily Cash Benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Convalescence Benefit","options":[],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Joint Hospitalisation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Day Care Procedure Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Surgery Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Accidental Hospitalisation Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Broken Bones","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Burns","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Personal Accident Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if opting for this cover","type":"yes-no","label":"Critical Illness Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select applicable option","type":"choice","label":"Pre-existing Disease Waiting Period Waiver","options":["NA","Yes","No"],"required":null,"pdf_field":""},{"help":"Select applicable option","type":"choice","label":"30 days Waiting Period Waiver","options":["NA","Yes","No"],"required":null,"pdf_field":""},{"help":"Select applicable option","type":"choice","label":"Maternity Benefit Waiting Period Waiver","options":["NA","Yes","No"],"required":null,"pdf_field":""},{"help":"Specify diseases or procedures if applicable","type":"text","label":"Specified disease/procedure waiting period waiver","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Applicable only to credit linked policies","type":"text","label":"Membership ID/ Employee Number/ Account Number pertaining to Credit (#)","options":[],"required":true,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"text","label":"Name of the Financier (#)","options":[],"required":true,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"text","label":"Credit Tenure (#)","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":"Category of insured person","type":"text","label":"Category","options":[],"required":true,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"text","label":"Applicant / Co-applicant (#)","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":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"date","label":"Credit sanctioned date (#)","options":[],"required":true,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"amount","label":"Credit Amount / outstanding credit amount (#)","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer or other insured","type":"text","label":"Relationship with the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Occupation or designation of insured person","type":"text","label":"Designation/ Occupation","options":[],"required":true,"pdf_field":""},{"help":"Declare any existing illness","type":"text","label":"Any existing illness","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":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","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","type":"text","label":"Bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Transaction reference number for card payments","type":"text","label":"For Credit/Debit Card - Transaction Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Transaction Date","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 claim payment","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":""}],"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 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":""},{"help":"Tick 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":"ASBA Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing (DD/MM/YYYY)","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Political Exposure and Entity Type","fields":[{"help":"Select Yes or No","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":"Select Yes or No","type":"yes-no","label":"Are you a Non-Profit Organization?* (only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select applicable organisation type","type":"choice","label":"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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign the form","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 (DD/MM/YYYY)","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Agent or intermediary 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 signature or stamp","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and agent"}],"deadlines":[],"applies_to":"Group Smart Cash - Micro Insurance policies","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, 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 the insurer of any changes 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 regulatory authorities.","Policy and service communications will be sent by email unless physical copies are requested.","The proposer consents to KYC verification through government or regulatory portals.","The proposer confirms premiums are paid from legitimate sources and understands the insurer's rights under anti-money laundering laws.","The insurance advisor declares that the policy features and terms have been explained to the proposer.","No rebates or inducements are allowed under the Insurance Act, and violations may result in fines.","If the proposer is a person with disability, they may authorize a representative to assist in completing the form.","The vernacular declaration confirms the proposer understands the form and terms in their language."],"dropped_labels":22},"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/5518-group-smart-cash-micro-insurance-proposal-form"}