{"id":5533,"title":"Machinery Breakdown Insurance Proposal Form","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Machinery_Breakdown_Insurance_Proposal_Form_ZK_26_27_v1_17072026_e2e4e14a17.pdf","sha256":"a8e4948e6102d8c4bd12da02fc4389d5501448eecaa3cbddcde0723de7dbcca4","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or corporate entities to apply for machinery breakdown insurance coverage by providing details about the proposer, machinery, and insurance requirements.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","Provide additional sheets if space is insufficient, indicating the question number.","The policy liability starts only after acceptance and premium receipt.","The proposal form forms the basis of the insurance contract.","Use original and accurate information; misrepresentation may void the policy.","For individual customers, PAN or Form 60 is mandatory if premium exceeds ₹50,000.","For electronic insurance account, email ID is mandatory.","The total claim share percentage for nominees must not exceed 100%.","The proposer may be classified as High Net Worth Individual (HNI) by ticking the relevant box.","The insurer is not liable if NEFT transactions fail.","Submission of proposal or payment does not guarantee policy issuance."],"title":"Machinery Breakdown Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer/Owner’s Details","fields":[{"help":"Enter full name of the proposer in block letters","type":"text","label":"Proposer’s Name*","options":[],"required":true,"pdf_field":""},{"help":"Specify the trade or business of the proposer","type":"text","label":"Proposer's Trade or Business*","options":[],"required":true,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter GST Identification Number if applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address (Line 1)","options":[],"required":false,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address (Line 2)","options":[],"required":false,"pdf_field":""},{"help":"Enter nearest landmark to the address","type":"text","label":"Nearest Landmark","options":[],"required":false,"pdf_field":""},{"help":"Enter city or district","type":"text","label":"City / District","options":[],"required":false,"pdf_field":""},{"help":"Enter registered or permanent address","type":"text","label":"Registered Office Address / Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Communication Address same as the Registered Office Address / Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide communication address details if different","type":"text","label":"If ‘No’, please provide below","options":[],"required":false,"pdf_field":""},{"help":"Enter state of communication address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Enter country","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Enter communication postal address","type":"text","label":"Communication (Postal) Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN or attach Form 60 if premium exceeds ₹50,000","type":"text","label":"PAN* / Form 60 (mandatory if premium is above `50,000)","options":[],"required":true,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"Select income range","type":"choice","label":"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":"Enter GSTIN if applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable identity and address proofs","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [(ü) Tick whichever is applicable]","options":["PAN","Aadhaar","Passport","Driving Licence","Voter ID Card","Others (Please specify)"],"required":false,"pdf_field":""},{"help":"Provide corporate details including CKYC and PAN","type":"text","label":"For Corporate customers / Firms, please share below details:","options":[],"required":false,"pdf_field":""},{"help":"Enter name, designation, and CKYC of authorized signatory","type":"text","label":"Please share the below details for the Authorised Signatory:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you have an existing policy","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide existing policy number if applicable","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you are a non-profit organization","type":"yes-no","label":"Are you a Non-profit Organization?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter bank name for hypothecation if applicable","type":"text","label":"Hypothecation Details: Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter full address of the plant location","type":"text","label":"Address where the plant to be insured is located*","options":[],"required":true,"pdf_field":""},{"help":"Enter city or district of plant location","type":"text","label":"City / District:","options":[],"required":false,"pdf_field":""},{"help":"Enter pin code of plant location","type":"number","label":"Pin Code:","options":[],"required":false,"pdf_field":""},{"help":"Enter state of plant location","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"Enter country of plant location","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Enter nearest railway station and distance from plant","type":"text","label":"Nearest Railway Station and Distance","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance and Machinery Details","fields":[{"help":"Answer if the listed items cover the entire plant","type":"yes-no","label":"1. Do the items listed represent the whole of the plant","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if currently insured","type":"yes-no","label":"2. a) Are you at present Insured?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if any insurer declined coverage","type":"yes-no","label":"3. Has any Company a) Declined to insure any of the machinery now proposed?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if any defects or damages exist","type":"yes-no","label":"4. a) Are you aware of any defects/ damages existing in the machinery?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if machinery was damaged in last 3 years","type":"yes-no","label":"5. a) Has your machinery sustained any damage from breakdown or other cause during last 3 years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if periodic inspections are done","type":"yes-no","label":"6. a) Are regular periodical inspections of the machinery carried out?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick and specify limits for additional covers if desired","type":"checkbox","label":"7. On payment of additional premium do you wish to cover the following? If yes, provide limits of indemnity","options":["Escalation Amount/percentage","Express Freight (excluding Air Freight), Overtime and Holiday rates of Wages","Air Freight","Owners surrounding property","Third Party Liability - AOA (Any One Accident)","Third Party Liability - AOY (Any One Year)","Additional Customs Duty","Any other Additional cover you wish to opt for Please specify"],"required":false,"pdf_field":""},{"help":"Enter each machinery separately with columns: Sr. No., Quantity, Description/Type/Model/Capacity/Sr. No/HP/KVA/Volts/Amps/RPM, Maker’s Name and Country of origin, Year of Make, Sum Insured (INR)","type":"table","label":"Schedule of Machinery to be Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account and Payment 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":false,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Provide 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 an 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 premium payment","type":"text","label":"Details as per premium cheque to be used for electronic fund transfer","options":[],"required":false,"pdf_field":""},{"help":"Tick if cancelled cheque from other bank is submitted","type":"checkbox","label":"Cancelled cheque submitted of other bank","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter account holder's name","type":"text","label":"Account Holder name","options":[],"required":false,"pdf_field":""},{"help":"Provide payment instrument details such as Cheque/DD number, bank, branch, transaction reference, date, IFSC/MICR code, amount","type":"text","label":"Payment Details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details (Applicable for individual customers)","fields":[{"help":"Enter full name of nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship with proposer","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Provide nominee's bank details","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage share of claim (total must not exceed 100%)","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Provide appointee details if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Agent declares having explained policy features; signature and stamp required","type":"signature","label":"Declaration for Agent","options":[],"required":true,"pdf_field":""},{"help":"Proposer's signature or thumb impression","type":"signature","label":"Signature / Stamp of the 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":""},{"help":"Declaration in local language by intermediary and proposer with signatures","type":"signature","label":"Vernacular Declaration","options":[],"required":false,"pdf_field":""},{"help":"Proposer declares all information is true and consents to KYC verification and electronic communication","type":"checkbox","label":"Declaration","options":[],"required":true,"pdf_field":""},{"help":"Proposer confirms premiums paid from bonafide sources and understands company rights","type":"checkbox","label":"AML Declaration","options":[],"required":true,"pdf_field":""},{"help":"Declare if associated with PEP","type":"yes-no","label":"Are You or any of the proposed applicants or close relatives is/are associated to Politically Exposed Person (PEP)?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Declare if non-profit organization","type":"yes-no","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Proposer's signature or thumb impression","type":"signature","label":"Signature/Thumb impression of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized representative if applicable","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":false,"pdf_field":""},{"help":"Signature and authorization for representative if proposer is PWD","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent"}],"deadlines":[],"applies_to":"Machinery Breakdown Insurance","attachments":["Additional sheets if more space is needed for answers","Proof of Identity and Proof of Address documents","Cancelled cheque for electronic fund transfer","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["The proposer declares all information provided is true and complete to the best of their knowledge.","The proposer consents to KYC verification through various government portals.","The proposer agrees to receive policy and service communications via email.","The proposer confirms premiums are paid from bonafide sources and understands the insurer's rights under AML laws.","The proposer declares if associated with Politically Exposed Persons (PEP).","The proposer declares if they are a Non-Profit Organization (if applicable).","The proposer authorizes a representative if they are a person with disability."],"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/5533-machinery-breakdown-insurance-proposal-form"}