{"id":5524,"title":"Health Super Top Up Proposal Form (Premium)","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Health_Super_Top_Up_Premium_GO_GREEN_Proposal_Form_ZK_V1_25_26_22042025_10e306a1b6.pdf","sha256":"bf34316176802daaacaadc383071eac0d8edd47189fd90814357efc33c1bfe80","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Health Super Top Up insurance policy with Zurich Kotak General Insurance Company. The proposer fills the form to provide personal, health, and coverage details for underwriting and premium calculation.","notes":["Fill the form in BLOCK LETTERS.","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 by policyholder.","Use original documents for proof of identity and address.","If additional space is needed, attach extra sheets referencing question numbers.","Online payment should be made by the policyholder himself.","Policy issuance is subject to underwriting and receipt of premium in full and realization.","The form includes statutory warning about prohibition of rebates under Insurance Act."],"title":"Health Super Top Up Proposal Form (Premium)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Detail","fields":[{"help":"Select the plan type","type":"choice","label":"Plan Name*","options":["Family Floater","Individual"],"required":true,"pdf_field":""},{"help":"Select the policy duration","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Indicate if you want to pay premium in installments","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select frequency if installment option is Yes","type":"choice","label":"Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""},{"help":"Date when the policy coverage should start","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or intermediary"},{"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":"Format 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":"Include Address Line 1, Line 2, Nearest Landmark, State","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is Correspondence Address same as Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If different from permanent address","type":"text","label":"Correspondence Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Title","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Occupation*","options":["Salaried","Professionals","Student","Housewife","Retired","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Profession*","options":["Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City/District","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":null,"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":"Permanent Account Number","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Tick 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","Zurich / Kotak Group Employees"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, Policy No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Customer Reference 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":"Insured Information","fields":[{"help":"Provide Name, Relation with Proposer, Date of Birth (DD/MM/YYYY), Height (cm), Weight (kg), Occupation, Marital Status, Gender, ABHA Number for each insured person","type":"table","label":"Insured Details","options":[],"required":true,"pdf_field":""},{"help":"Provide Nominee Name, Relationship with Proposer, Date of Birth, Mobile Number, Email ID, Present and Permanent Address, Bank Name and Account Details, % of claim share (total 100%), and if nominee is minor, Appointee details","type":"table","label":"Nominee Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Hospitalisation Information","fields":[{"help":"Answer for each insured person","type":"yes-no","label":"Are you currently in good mental and physical health – Yes/No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide accident details if applicable","type":"text","label":"If any accident in past please give details: Year of Accident, Accident resulting in deformity or disability hampering mobility","options":[],"required":false,"pdf_field":""},{"help":"Provide details if insured has existing health insurance","type":"text","label":"Existing Health Insurance Details: Type of Policy, Period of Insurance, Insurance Company, Base Annual Sum Insured (`)","options":[],"required":false,"pdf_field":""},{"help":"Provide claim history if any","type":"text","label":"Details of claims: Ailment for which claim was made, Claim amount paid/rejected, Year of claim","options":[],"required":false,"pdf_field":""},{"help":"List any pre-existing diseases","type":"text","label":"Any Pre-existing diseases","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"If payment by cheque or DD, provide number","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Provide transaction reference for card payments","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of card transaction","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details","fields":[{"help":"Indicate if you have an Electronic Insurance Account","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Email for EIA registration","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you want the insurer to create EIA account","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide bank account details for electronic fund transfer of payments and claims","type":"text","label":"Bank Account Details","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Location where form is signed","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"Sign or thumb impression to confirm declarations","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":""},{"help":"If proposer requires assistance, sign here","type":"signature","label":"Vernacular Declaration Signature / Thumb impression of Proposer","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health Super Top Up insurance policy proposal","attachments":["Additional sheets if space is insufficient to answer any question","Documents for existing illness or hospitalization if applicable","Cancelled Cheque for bank details"],"declarations":["All information provided is true, complete and accurate to the best of the proposer's knowledge.","The policy will be issued subject to underwriting and receipt of full premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent to insurer to seek medical and other information for underwriting and claims.","Consent to share proposal and medical records with government and regulatory authorities.","Policy and service communications will be sent by email unless physical copy requested.","Consent to verify identity/address through government databases for KYC.","Consent to share medical records via ABHA number for underwriting and claims.","Proposer declares if they qualify as High Net Worth Individual (HNI).","Disclosure if proposer or relatives are Politically Exposed Persons (PEP).","Consent to block premium payment via BIMA ASBA facility from bank account."],"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/5524-health-super-top-up-proposal-form-premium"}