{"id":5527,"title":"Health Super Top Up Proposal Form (Prime)","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_Prime_GO_GREEN_Proposal_Form_ZK_V1_25_26_22042025_394506c23d.pdf","sha256":"4fef3197131c6fd71c584cec3ac41485424bf7222d1e0a3772c5173ed4ef8ca3","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 coverage details.","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 after acceptance and premium receipt.","Provide all information fully, accurately, and correctly.","Policy is voidable if any material information is untrue, incorrect, or withheld.","Attach additional sheets if needed, indicating question number.","Online or credit card premium payment must be made by the policyholder; third party payments not allowed.","Use original documents for proof where required.","Electronic fund transfer is mandatory for payments and claims.","No rebate is allowed as per Insurance Act 1938."],"title":"Health Super Top Up Proposal Form (Prime)","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"],"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":"Indicate if installment option is chosen","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter the proposed policy start date","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":""},{"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, City/District, State, Pin Code","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, include full 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":"text","label":"Profession*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"","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":"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":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","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":"","type":"text","label":"Name in Full*","options":[],"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":"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":"","type":"choice","label":"Marital Status*","options":["Single","Married","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"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":""}],"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":"Include Name, Date of Birth, Relationship with Nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"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":"Provide details for each insured person","type":"table","label":"Details of hospitalization for the illness / ailment / Medicine / Test / Surgery","options":["Insured 1","Insured 2","Insured 3","Insured 4","Insured 5","Insured 6"],"required":false,"pdf_field":""},{"help":"Tick Yes for applicable conditions","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)","options":["Kidney and urinary system","Pregnant / Gynaecological Disorders / any disorder of Prostrate","Birth Defects","Accidents / burns","Disorders of the Eyes / Ears / Nose / throat","Disorders of the circulatory system / Heart Disease/ hypertension","Respiratory Infections and Diseases, Asthma","Bones and Joints, Spondylitis / arthritis etc.","Diseases of Stomach, Intestines, liver, appendix","Mental psychiatric Disorders","Nervous system Disorders","Infections / Allergies","HIV / AIDs","Cancer / Tumor / Cyst","Nutritional / Endocrinal disorders / Diabetes","High BP, Cholesterol"],"required":false,"pdf_field":""},{"help":"","type":"number","label":"If any accident in past please give details: 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 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":false,"pdf_field":""},{"help":"","type":"text","label":"Name the medication and duration since on treatment","options":[],"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":"Diabetes Mellitus - If Yes provide duration, type I or II and name of medication","options":[],"required":false,"pdf_field":""},{"help":"If Yes, provide documents","type":"yes-no","label":"Any hospitalization in the past – Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Period of hospitalization","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Claims","fields":[{"help":"","type":"text","label":"Ailment for which claim was made","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Claim amount paid / rejected","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Year of claim","options":[],"required":false,"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":false,"pdf_field":""},{"help":"","type":"text","label":"Any Pre-existing diseases","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":"","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":""}],"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":false,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Mandatory","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"","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 account number, bank name, IFSC/MICR code, account holder name","type":"text","label":"Bank Account Details","options":[],"required":false,"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 Proposer*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","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":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"If proposer is person with disability","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":false,"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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health Super Top Up insurance policy proposals","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 details"],"declarations":["All premiums paid are from bonafide sources and not from proceeds of crime.","Information provided is true and complete to the best of knowledge and forms basis of insurance policy.","Notify insurer in writing of any change in occupation or health after proposal submission but before acceptance.","Consent to insurer seeking medical and other information for underwriting and claims settlement.","Consent to insurer sharing proposal and medical records with government or regulatory authorities.","Policy and service communications will be sent electronically unless physical copy requested.","Consent to verify identity/address through official registries for KYC purposes.","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":4},"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/5527-health-super-top-up-proposal-form-prime"}