{"id":5521,"title":"Health Premier Proposal Form (Elite)","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_Elite_GO_GREEN_Proposal_Form_ZK_26_27_v1_17032026_c0711beb55.pdf","sha256":"a9fb8b0681de9c7f122ea239d192b06541a36ecad12cd028d3fa86611e93f0ab","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase the Health Premier Elite insurance plan from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and coverage details for underwriting.","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; payment must be made by policyholder.","Use additional sheets if more space is needed and indicate question number.","Electronic Insurance Account (EIA) email ID is mandatory if opting for EIA.","Total claim share percentage for nominees must not exceed 100%.","Policy issuance is subject to underwriting and receipt of premium in full and on time.","No rebates or inducements are allowed as per Insurance Act 1938."],"title":"Health Premier Proposal Form (Elite)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"","type":"choice","label":"Plan Name*","options":["Elite"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Base Annual Sum Insured*","options":["10 lac","15 lac","20 lac","25 lac"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"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":"Date when coverage should begin","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer’s Information","fields":[{"help":"Use BLOCK LETTERS","type":"text","label":"First Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Use BLOCK LETTERS","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 from permanent address","type":"text","label":"Correspondence Address*","options":[],"required":true,"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":"DD/MM/YYYY format","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","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number for tax purposes","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"Tick all 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","Others"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Columns: Cover, Yes/No; includes Compassionate Visit, Maternity Benefit, New Born Baby Cover, Vaccination Expenses, Critical Illness Cover, Personal Accident Cover","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":""},{"help":"","type":"yes-no","label":"Would you like to opt for 24 months Pre-existing disease waiting period","options":["Yes","No"],"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":"Full name of insured person","type":"text","label":"Name in Full*","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relation with the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of insured","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":"Columns: Medical condition, Insured 1 to Insured 6; tick Yes/No for each condition","type":"table","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following","options":[],"required":null,"pdf_field":""},{"help":"Includes smoking/tobacco consumption and alcohol consumption with duration and quantity","type":"table","label":"Section B: Lifestyle Information","options":[],"required":null,"pdf_field":""},{"help":"Provide details of existing health insurance","type":"text","label":"Section C: Existing Health Insurance Details","options":[],"required":null,"pdf_field":""},{"help":"Details of past claims including ailment, claim amount, year of claim","type":"table","label":"Section D: Details of claims","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Relationship 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":false,"pdf_field":""},{"help":"Email address of nominee","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Total claim share percentage must not exceed 100%","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name, date of birth, and relationship of appointee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or Demand Draft number if payment by these modes","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Bank name 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 for payment","type":"text","label":"Bank","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":"Declarations and Signatures","fields":[{"help":"Sign or affix 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 who explained the form","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health Premier Elite individual and family floater health insurance plans","attachments":["Additional sheets if space is insufficient to complete details","Proof of Identity and Proof of Address documents as applicable","Cancelled Cheque for bank account details","Insurance Repository Application form (if opting for EIA account creation)"],"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 the company seeking medical and other information for underwriting and claims settlement.","Consent to share proposal and medical records with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","Consent to verify identity/address through government registries for KYC purposes.","Consent to share medical records with insurer/TPA via ABHA number if available.","Declaration of High Net Worth Individual status if applicable.","Declaration that premiums are paid from legitimate sources and compliance with anti-money laundering laws.","Consent to block premium payment under BIMA ASBA facility upon proposal acceptance."],"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/5521-health-premier-proposal-form-elite"}