{"id":5525,"title":"Health Super Top Up Proposal Form (Excel)","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_Excel_GO_GREEN_Proposal_Form_ZK_V1_25_26_22042025_2db0468cf6.pdf","sha256":"ff6061a497d49da7bc5e83e7265fbf66f9e0b8ba94819b6135545e6c6565c550","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase the Health Super Top Up insurance policy from Zurich Kotak General Insurance Company. The proposer fills this form with personal, health, and payment details to apply for the insurance.","notes":["Fill the proposal form in BLOCK LETTERS.","Fields marked with * are mandatory.","Issuance of form does not mean acceptance of proposal; policy liability starts only after acceptance and premium receipt.","Provide all information fully, accurately and correctly.","Policy is voidable if any information is untrue, incorrect, incomplete or withheld.","Attach additional sheets if needed, indicating question number.","Online or credit card premium payment must be made by policyholder; third party payments not allowed.","Use original documents for proofs and claims.","Electronic fund transfer is mandatory for payments and refunds.","No rebate is allowed as per Insurance Act 1938."],"title":"Health Super Top Up Proposal Form (Excel)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Detail","fields":[{"help":"Select the plan name","type":"choice","label":"Plan Name*","options":["Family Floater","Individual","Excel"],"required":true,"pdf_field":""},{"help":"Select the policy period","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Select if you want installment option","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter the proposed start date of the policy","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""},{"help":"Select installment frequency if installment option is Yes","type":"choice","label":"Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section I: 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":"Enter date of birth in 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"],"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":"Fill only if different from Permanent Address","type":"text","label":"Correspondence Address*","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":"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 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":["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":"","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","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":""},{"help":"","type":"yes-no","label":"Zurich / Kotak Group Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide policy number if existing policy","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 Relationship Number","type":"text","label":"If Yes, CRN","options":[],"required":false,"pdf_field":""},{"help":"Employee ID if applicable","type":"text","label":"If yes, Employee ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section III: Insured Information","fields":[{"help":"Fill details for each insured person: Name in Full*, Relation with the Proposer*, Date of Birth DD/MM/YYYY*, Height (cm)*, Weight (kg)*, Occupation*, Marital Status*, Gender*, ABHA Number","type":"table","label":"Insured Details","columns":["Name in Full*","Relation with the Proposer*","Date of Birth DD/MM/YYYY*","Height (in cm)*","Weight (in kg)*","Occupation*","Marital Status*","Gender*","ABHA Number"],"options":[],"required":true,"pdf_field":""},{"help":"Fill nominee details including Relationship with Proposer*, Nominee Date of Birth*, Nominee Mobile Number, Nominee Email ID, Nominee Name*, Nominee Present and Permanent Address, Nominee Bank Name and Account Details, % of claim share* (total 100%), and if nominee is minor, details of Appointee","type":"table","label":"Nominee Details","columns":["Relationship of Nominee with Proposer*","Nominee Date of Birth DD/MM/YYYY*","Nominee Mobile Number","Nominee Email ID","Nominee Name*","Nominee Present Address","Nominee Permanent Address","Nominee Bank Name and Account Details","% of claim share*","Name of the Appointee","Date of Birth DD/MM/YYYY","Relationship with the Nominee","Name of the Nominee"],"options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section IV: Medical and Hospitalisation, Lifestyle, Existing Insurance and Claims Details","fields":[{"help":"Are you currently in good mental and physical health?","type":"yes-no","label":"Section A: Medical and Hospitalisation","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide year of accident and if it resulted in deformity or disability hampering mobility","type":"text","label":"If any accident in past please give details","options":[],"required":false,"pdf_field":""},{"help":"Do you or any insured have smoking/tobacco or alcohol consumption habits? If yes, provide duration and quantity per day","type":"yes-no","label":"Section B: Lifestyle Information","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details of existing health insurance policies if any","type":"table","label":"Section C: Existing Health Insurance Details","columns":["Type of Policy","Period of Insurance","Insurance Company","Base Annual Sum Insured (`)"],"options":[],"required":false,"pdf_field":""},{"help":"If yes, provide documents and name of medication and duration","type":"yes-no","label":"Are you currently suffering or previously suffered from any illness and on continuous medication?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Have you undergone any medical test or health check in past 6 months? If yes, mention abnormal results","options":[],"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":"Provide details of ailment for which claim was made, claim amount paid/rejected, year of claim","type":"table","label":"Section D: Details of claims","columns":["Ailment for which claim was made","Claim amount paid / rejected","Year of claim"],"options":[],"required":false,"pdf_field":""},{"help":"Provide details if any","type":"text","label":"Any Pre-existing diseases","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section IV: Payment Details","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Bank name on which cheque/DD is drawn","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":"Enter transaction reference number for card payment","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":"Do you have an EIA Account?","type":"yes-no","label":"Electronic Insurance Account Details of Proposer","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Email ID mandatory for EIA","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Select if you want the company 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":false,"pdf_field":""},{"help":"Provide bank account details for electronic fund transfer","type":"text","label":"Bank Account Details","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No.","options":[],"required":true,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":true,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Tick if cancelled cheque is submitted","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":["Yes"],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"Sign or thumb impression here","type":"signature","label":"Signature / Thumb impression of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"If applicable, 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 complete details","Documents for continuous medication if applicable","Documents for past hospitalization if applicable","Cancelled cheque for bank account verification"],"declarations":["All premiums paid are from bonafide sources and not from proceeds of crime.","Information provided is true, complete and forms basis of insurance policy.","Policy comes into force only after full payment of premium.","Notify insurer in writing of any change in occupation or health after proposal submission and before risk acceptance.","Consent to insurer seeking medical and insurance information for underwriting and claims.","Consent to insurer sharing proposal and medical records with government/regulatory authorities.","Policy and service communications will be sent in soft copy to email provided unless physical copy requested.","Consent to verify identity/address through government portals for KYC.","Consent to share medical records with insurer/TPA via ABHA number if available.","Declaration of High Net Worth Individual status if applicable.","Disclosure of association with Politically Exposed Persons if applicable.","Consent to block premium payment under BIMA ASBA facility and debit from bank account upon acceptance."],"dropped_labels":8},"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/5525-health-super-top-up-proposal-form-excel"}