{"id":5519,"title":"Health Premier Proposal Form (Advantage)","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_Advantage_GO_GREEN_Proposal_Form_ZK_26_27_v1_17032026_58e0247cb3.pdf","sha256":"764df88c92dd2ab6b959c33cf3142278aab26fa3de4fff610317491534890148","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase the Health Premier Advantage insurance policy from Zurich Kotak General Insurance Company. The proposer fills this form with personal, health, and policy details.","notes":["Fill the form in BLOCK LETTERS.","All fields marked with * are mandatory.","Submission of this form or payment does not guarantee policy issuance.","Third party payments for premium are not allowed.","Use additional sheets if needed and indicate question number.","Online payment should be made by the policyholder himself.","The insurer may cancel the policy if premium is not received in full and on time.","The proposer must provide bank details for electronic fund transfer of claims/refunds.","The form includes a statutory warning about prohibition of rebates under Insurance Act."],"title":"Health Premier Proposal Form (Advantage)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"PROPOSAL DETAILS","fields":[{"help":"","type":"choice","label":"Individual / Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Plan Name*","options":["Advantage"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Base Annual Sum Insured*","options":["3 lac","4 lac","5 lac","7.5 lac","10 lac"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Fill only 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":"","type":"choice","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"PROPOSER’S INFORMATION","fields":[{"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":"Fill if country is not India","type":"text","label":"If ‘No’, please provide below City/District, State, Country","options":[],"required":false,"pdf_field":""},{"help":"Enter valid mobile number","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Form 60 (only in case the customer does not have PAN No.)","options":["Form 60"],"required":false,"pdf_field":""},{"help":"If available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"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":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address* - Address (Line 1)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill if correspondence address is different","type":"text","label":"Correspondence Address - Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Title Mr. / Miss / Mrs. / M/s / Others","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":false,"pdf_field":""},{"help":"If applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Annual Income","options":["Upto 2.5 lacs","2.5 - 6 lacs","6 - 10 lacs","10 - 15 lacs","15 - 20 lacs","20 - 25 lacs",">25 lacs"],"required":false,"pdf_field":""},{"help":"Tick all applicable proofs","type":"checkbox","label":"Please share the following for authentication purpose: Proof of Identity (POI) and Proof of Address (POA) [Tick (ü) whichever is applicable]","options":["PAN","Ration Card","Passport","Driving Licence","Voter ID Card","Others (Please specify)"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"COVERAGE DETAILS","fields":[{"help":"Select zone based on location","type":"choice","label":"Zone*","options":["Zone I","Zone II","Zone III"],"required":true,"pdf_field":""},{"help":"Select Yes or No for each benefit","type":"table","label":"Would you like to opt for the following Cover Details (Yes / No)","options":["Home Nursing Benefit","Compassionate Visit","Additional Sum Insured equivalent to Base Sum Insured","Daily cash for Accompanying an Insured Child","Critical Illness Cover","Personal Accident Cover","Cap on room Rent"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"INSURED INFORMATION","fields":[{"help":"","type":"choice","label":"Marital Status*","options":["Single","Married","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name in Full*","options":[],"required":true,"pdf_field":""},{"help":"Relation to proposer (e.g. self, spouse, child)","type":"text","label":"Relation with the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (in cm)*","options":[],"required":true,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight (in kg)*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"HEALTH AND MEDICAL INFORMATION","fields":[{"help":"Tick Yes or No for each condition and insured person","type":"table","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following (tick Yes/No for each insured): Cancer / Tumor / Cyst, Nutritional / Endocrinal disorders / Diabetes, Mental psychiatric Disorders, Nervous system Disorders, Respiratory Infections and Diseases, Asthma, Bones and Joints, Spondylitis / arthritis etc., Diseases of Stomach, Intestines, liver, appendix, Kidney and urinary system, Birth Defects, Accidents / burns, Accident resulting in deformity or disability hampering mobility","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide duration and quantity per day","type":"choice","label":"Smoking / Tobacco consumption – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide duration and quantity","type":"choice","label":"Alcohol consumption- Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide documents and details","type":"choice","label":"Any hospitalization in the past – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Have you undergone any medical test or health check–up in the past 6 months? If yes, mention if any abnormal result detected","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Are you currently in good mental and physical health – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide documents, medication name and duration","type":"choice","label":"Are you currently suffering or previously suffered from any illness and on continuous medication for same- Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Diabetes Mellitus - If Yes provide duration, type I or II and name of medication","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"High BP, Cholesterol - If Yes since when and medication being taken","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Have You or any person proposed to be insured under the Policy has ever been refused insurance cover by an insurance company or been accepted on special terms? (YES / No)","options":["Yes","No"],"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":"Format DD/MM/YYYY","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":"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":"If nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee - Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"ELECTRONIC INSURANCE ACCOUNT DETAILS AND PAYMENT DETAILS","fields":[{"help":"","type":"choice","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":"Email for EIA account","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If payment 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":"Bank name","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"If payment by card","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Tick if cancelled cheque submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":["Yes"],"required":false,"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":"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 of intermediary","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Health Premier Advantage insurance policy proposal","attachments":["Additional sheets if space is insufficient","Documents for any past hospitalization","Cancelled cheque for bank account","Proof of Identity and Proof of Address"],"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.","Notify the insurer in writing of any change in occupation or health after proposal submission and before acceptance.","Consent to insurer seeking medical and other information for underwriting and claims.","Consent to insurer sharing proposal and medical information with regulatory authorities.","Policy and service communications will be sent electronically unless physical copy requested.","Consent to KYC verification through government portals.","Consent to sharing medical records via ABHA number if available.","Declaration of High Net Worth Individual status if applicable.","Declaration that premiums are paid from bonafide sources and compliance with AML laws.","Disclosure of association with Politically Exposed Persons if any.","Declaration if proposer is a Non-Profit Organization."],"dropped_labels":11},"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/5519-health-premier-proposal-form-advantage"}