{"id":5522,"title":"Health Premier Proposal Form (Total)","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_Total_GO_GREEN_Proposal_Form_ZK_26_27_v1_17032026_de5d3d6ac0.pdf","sha256":"6e52d3c285915d256d060cc8149fa4695b3cbff068f853682e849367b771541e","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families to apply for the Health Premier insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and coverage details for insurance underwriting.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Issuance of form does not mean acceptance of proposal.","Provide all information fully and accurately.","Attach additional sheets if needed and indicate question number.","Online or credit card premium payment must be made by policyholder only; third party payments not allowed.","Use original documents for proofs and claims.","Proposer must sign and date the form.","If proposer is person with disability, authorized representative can assist and sign.","EIA account email ID is mandatory if applicable."],"title":"Health Premier Proposal Form (Total)","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"","type":"choice","label":"Plan Name*","options":["Total","Base Annual Sum Insured*"],"required":true,"pdf_field":""},{"help":"Select the sum insured amount","type":"choice","label":"Base Annual Sum Insured*","options":["2 lac","3 lac","4 lac","5 lac","7.5 lac","10 lac","15 lac","20 lac","25 lac","50 lac","75 lac","100 lac","150 lac","200 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 of installment payment if applicable","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":""}],"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":"","type":"yes-no","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address* - Address (Line 1)","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"Permanent Account Number","type":"text","label":"PAN Number*","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":"text","label":"Profession*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","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":"","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Annual Income","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable proofs","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":"Name of insured person for maternity benefit","type":"text","label":"Please mention the Insured for whom Maternity is opted","options":[],"required":false,"pdf_field":""},{"help":"Select zone based on location","type":"choice","label":"Please select the Zone","options":["Zone I","Zone II","Zone III"],"required":false,"pdf_field":""},{"help":"Optional lower waiting period","type":"choice","label":"Would you like to opt for lower Pre-existing disease waiting period","options":["24 months"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"","type":"text","label":"Name in Full*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status*","options":["Single","Married","Others"],"required":true,"pdf_field":""},{"help":"","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":"","type":"number","label":"Height (in cm)*","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Weight (in kg)*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"If not created, visit https://healthid.ndhm.gov.in/","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""},{"help":"Tick 'YES' for applicable insured persons","type":"checkbox","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following (Cancer, Diabetes, HIV, etc.)","options":["Cancer / Tumor / Cyst","Nutritional / Endocrinal disorders / Diabetes","Mental psychiatric Disorders","Nervous system Disorders","Infections / Allergies","HIV / AIDs","Disorders of the Eyes / Ears / Nose / throat","Disorders of the circulatory system / Heart Disease/ hypertension"],"required":null,"pdf_field":""},{"help":"If Yes, provide documents and period of hospitalization","type":"yes-no","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 month if yes then please mention if any abnormal result detected","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you currently in good mental and physical health – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide documents, name medication and duration","type":"yes-no","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":""}],"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":"","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":"","type":"text","label":"Where Nominee is a minor, give details of Appointee - Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"","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 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":"","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":"Consent to block premium amount in bank account","type":"checkbox","label":"ASBA Declaration","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"","type":"signature","label":"Signature / Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Health Premier insurance policy proposals for individual and family floater plans","attachments":["Documents for any past hospitalization if applicable","Additional sheets if space is insufficient for answers","Cancelled cheque for bank account verification"],"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 company in writing of any change in occupation or health before risk acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical records with insurer, TPA, and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy requested.","Consent to verify identity/address through government or regulatory portals for KYC.","Consent to share 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.","Acknowledgement that no rebates are allowed as per Insurance Act 1938.","Declaration by intermediary that contents and terms have been explained to proposer."],"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/5522-health-premier-proposal-form-total"}