{"id":5523,"title":"Health Premier Proposal Form (Standard)","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_Standard_GO_GREEN_Proposal_Form_ZK_26_27_v1_17032026_1fd15c7cc1.pdf","sha256":"60677fece34d8f12ec6b62af715667878cbce185770cf35ce2759fa8930181ac","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Health Premier insurance policy 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.","Fields marked with * are mandatory.","Submission of this form or payment does not guarantee policy issuance.","Attach additional sheets if needed and indicate question number.","Online or credit card premium payment must be made by the policyholder only; third party payments are not allowed.","Use original documents for proof and hospitalization details.","The company reserves the right to accept or reject the proposal at its sole discretion."],"title":"Health Premier Proposal Form (Standard)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"PROPOSER’S INFORMATION","fields":[{"help":"","type":"choice","label":"Plan Name*","options":["Standard"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Base Annual Sum Insured*","options":["2 lac"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"If installment option is yes","type":"choice","label":"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":"DD/MM/YYYY","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":null,"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":"choice","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":"","type":"choice","label":"Title Mr. / Miss / Mrs. / M/s / Others","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":null,"pdf_field":""},{"help":"","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":"text","label":"Annual Income","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","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":"text","label":"Profession*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable","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":""},{"help":"","type":"checkbox","label":"Form 60 (only in case the customer does not have PAN No.)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Others (Please specify): _______________","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Customer Relationship Number","type":"text","label":"If yes, CRN","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If yes, Employee ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"COVERAGE DETAILS","fields":[{"help":"Select Yes or No for each benefit","type":"checkbox","label":"Health Protect Rider (UIN: ZUKHLIA25055V022425) - Would you like to opt for the following Benefits under the Health Protect Rider","options":["Claim Protect","Inflation Protect","Super NCB","Restoration Benefit Plus"],"required":null,"pdf_field":""},{"help":"Zone I: Mumbai and Delhi; 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":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"INSURED INFORMATION","fields":[{"help":"Fill details for each insured person: Marital Status*, Name in Full*, Relation with the Proposer*, Date of Birth DD/MM/YYYY*, Gender*, Height (in cm)*, Weight (in 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":"Fill Nominee Name*, Relationship with Proposer*, Nominee Date of Birth DD/MM/YYYY*, Nominee Mobile Number, Nominee Email ID, Nominee Present Address, Nominee Permanent Address, Nominee Bank Name and Account Details, % of claim share* (total must not exceed 100%)","type":"table","label":"Nominee Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"MEDICAL AND HOSPITALISATION INFORMATION","fields":[{"help":"Provide details or attach additional sheet if needed","type":"text","label":"Details of hospitalization for the illness / ailment / Medicine / Test / Surgery","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you currently in good mental and physical health – Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, provide documents","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":true,"pdf_field":""},{"help":"If yes, please give full detail","type":"yes-no","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":true,"pdf_field":""},{"help":"Provide details or attach additional sheet if needed","type":"text","label":"Any Pre-existing diseases","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable","type":"checkbox","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following (tick 'YES' if applicable): 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, Infections / Allergies, HIV / AIDs, Disorders of the Eyes / Ears / Nose / throat, Disorders of the circulatory system / Heart Disease/ hypertension, Pregnant / Gynaecological Disorders / any disorder of Prostrate","options":["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","Infections / Allergies","HIV / AIDs","Disorders of the Eyes / Ears / Nose / throat","Disorders of the circulatory system / Heart Disease/ hypertension","Pregnant / Gynaecological Disorders / any disorder of Prostrate"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Year of Accident","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Accident resulting in to deformity or disability hampering mobility","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, provide duration and quantity per day","type":"yes-no","label":"Smoking / Tobacco consumption – Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, provide duration and quantity","type":"yes-no","label":"Alcohol consumption- Yes / No","options":["Yes","No"],"required":false,"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":false,"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":"text","label":"Name the medication and duration since on treatment","options":[],"required":false,"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":"PAYMENT DETAILS","fields":[{"help":"Name of proposer","type":"text","label":"Received from Ms./Mrs./ Mr","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"a sum of `","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Through Cheque/DD","options":["Cheque","Demand Draft (DD)","Credit/Debit Card","Online Payment"],"required":false,"pdf_field":""},{"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":"","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","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":"Electronic Insurance Account","type":"choice","label":"Do you have an EIA Account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"","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":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature 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":""}],"filled_by":"proposer"},{"title":"DECLARATIONS AND SIGNATURES","fields":[{"help":"","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature / Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","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":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Health Premier individual health insurance policy proposal","attachments":["Additional sheets if space is insufficient for answers","Documents for any past hospitalization","Proof of Identity and Address documents as ticked","Cancelled cheque for bank details"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge.","The policy will be issued only after acceptance of the proposal and full premium payment.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and other information for underwriting and claims.","Policy and service communications will be sent by email unless physical copy is requested.","Consent is given to verify identity/address through government portals for KYC.","Consent is given to share medical records via ABHA number for underwriting and claims.","Proposer may be classified as High Net Worth Individual if declared.","All premiums are paid from bonafide sources and comply with anti-money laundering laws.","Proposer declares if associated with Politically Exposed Person (PEP).","Non-profit organization status must be declared if applicable.","Consent to block premium payment via BIMA ASBA facility upon proposal acceptance."],"dropped_labels":9},"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/5523-health-premier-proposal-form-standard"}