{"id":5526,"title":"Health Super Top Up Proposal Form (Classic)","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_Classic_GO_GREEN_Proposal_Form_ZK_V1_25_26_22042025_e61af1c9f8.pdf","sha256":"c38fb97f47ba55babd3663ff8841913a8e720727e66dd6b7518460ca1a5895b3","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Health Super Top Up 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.","Original documents may be required for verification.","Online or credit card payments must be made by the policyholder only; third party payments are not allowed.","Use additional sheets if space is insufficient and indicate question number.","The insurer reserves the right to accept or reject the proposal at its sole discretion.","Electronic fund transfer is mandatory for payments and claims; bank details must be provided.","The proposer must sign or provide thumb impression where indicated.","The form includes statutory warning about prohibition of rebates under Insurance Act."],"title":"Health Super Top Up Proposal Form (Classic)","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":"","type":"choice","label":"Type of cover:","options":["Classic"],"required":null,"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 installment payment","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Date when coverage should start","type":"date","label":"Proposed Start Date*","options":[],"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":""}],"filled_by":""},{"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":"Full name of proposer","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","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":"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":"Mobile number of proposer","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Email address of proposer","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":"Select 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":"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":"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","options":[],"required":true,"pdf_field":""},{"help":"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*","type":"table","label":"Nominee Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Hospitalisation Information","fields":[{"help":"","type":"yes-no","label":"Are you currently in good mental and physical health – Yes/No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","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":"Type of Policy, Period of Insurance, Insurance Company, Base Annual Sum Insured (`)","type":"text","label":"Existing Health Insurance Details","options":[],"required":false,"pdf_field":""},{"help":"If Yes, provide documents and medication details","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":false,"pdf_field":""},{"help":"","type":"text","label":"Have you undergone any medical test or health check-up in the past 6 months? If yes, mention if any abnormal result detected","options":[],"required":false,"pdf_field":""},{"help":"","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":"","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 demand draft, 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":"Bank name on cheque/DD","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 for payment","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":"Provide transaction reference number","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":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"","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":"Mandatory email for EIA account","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Select 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":""}],"filled_by":"proposer"},{"title":"Bank Account Details","fields":[{"help":"Bank account number for electronic fund transfer","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 no existing bank account","type":"checkbox","label":"No existing Bank Account","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","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":""}],"filled_by":"proposer"},{"title":"Declarations for Persons with Disability (PWD)","fields":[{"help":"Signature or thumb impression of proposer with disability","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":""}],"filled_by":"proposer or authorized representative"},{"title":"Declaration for Agent","fields":[{"help":"Proposer signature confirming agent declaration","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":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Health Super Top Up insurance policy (Classic plan)","attachments":["Additional sheets if space is insufficient to answer questions","Documents for continuous medication if applicable","Documents for past hospitalization if applicable","Cancelled Cheque for bank account verification"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge.","The policy will be issued only after full payment of premium and acceptance by the company.","The proposer will notify any change in occupation or health after submission but before acceptance.","The company may seek medical and other information from doctors, hospitals, employers, and insurers for underwriting and claims.","The company may share proposal and medical information with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","Consent is given to verify identity/address through government registries for KYC.","Consent is given to share medical records via ABHA number for underwriting and claims.","The proposer confirms premiums are paid from legitimate sources and not from proceeds of crime.","The proposer authorizes premium deduction via BIMA ASBA facility if applicable.","The proposer declares if they qualify as a High Net Worth Individual (HNI).","The proposer declares if they or close relatives are Politically Exposed Persons (PEP).","The intermediary declares that the proposal form contents and policy terms were explained to the proposer."],"dropped_labels":12},"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/5526-health-super-top-up-proposal-form-classic"}