{"id":5543,"title":"MediShield 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/Medi_Shield_Proposal_Form_ZK_v1_25_26_11082025_779f8b5a54.pdf","sha256":"ef0d59f8012601228171582d554ce4e5410cc5e73d7451289522f07449494123","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used to apply for the MediShield insurance policy designed for Persons with Disability, Mental Illness, and Persons with HIV/AIDS. It is filled by the proposer (applicant) seeking insurance coverage.","notes":["Fields marked with asterisk (*) are mandatory.","Only Indian Nationals can be covered under this policy.","Only one policy can be purchased for this product across all insurers.","Coverage is effective only after proposal acceptance and premium payment realization.","Use original documents for proof of identity and address.","Cancelled cheque should be of the same bank account for refund credit.","If ECS is selected for payment, submit standing instruction form available at branches.","Politically Exposed Person (PEP) and Non-Profit Organization declarations must be answered.","Policy and service communications will be sent in soft copy to the email provided unless physical copy requested."],"title":"MediShield Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Contact Details","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Coverage Details","fields":[{"help":"","type":"choice","label":"Policy Type","options":["Individual Basis"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy period","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance From to |","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Sum Insured","options":["4000000","5000000"],"required":null,"pdf_field":""},{"help":"Select applicable coverage","type":"choice","label":"Coverage opted:","options":["Pre-existing HIV/AIDS","Pre-existing Disability","Pre-existing HIV/AIDS and Disability"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Waiver of Co-payment opted","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":true,"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 mobile number","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","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":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Profession*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"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":"Include Address Line 1, Line 2, Nearest Landmark, Pin Code","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":false,"pdf_field":""},{"help":"","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","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":"Tick applicable documents","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":"Customer Relationship Number","type":"text","label":"If Yes, CRN","options":[],"required":false,"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":"","type":"text","label":"If yes, Employee ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If yes, Policy No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/ Existing Health Details of Insured","fields":[{"help":"","type":"yes-no","label":"Do you suffer from HIV/AIDS?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter current CD4 count","type":"number","label":"Current CD 4 count","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has your CD4 Count gone below 500 in the past 4 years?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of occurrences","type":"text","label":"If yes when and How many times","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you suffer from any other illness/ disease related to/ arising of/ associated to HIV/AIDS?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe other related illnesses","type":"text","label":"If Yes, please give details:","options":[],"required":false,"pdf_field":""},{"help":"Refer to listed disabilities on form","type":"yes-no","label":"Do you suffer from any disability as per the listed conditions mentioned below:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you suffer from any pre-existing illness other than Disability or HIV AIDS mentioned above?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide illness details and duration","type":"text","label":"If Yes, please specify details and the number of years you are suffering:","options":[],"required":false,"pdf_field":""},{"help":"Describe other physical disabilities","type":"text","label":"Do you have any other physical disability arising out of any illness / disease condition?","options":[],"required":false,"pdf_field":""},{"help":"Provide any other medical history","type":"text","label":"Any other previous medical details","options":[],"required":false,"pdf_field":""},{"help":"Create ABHA number if not available","type":"text","label":"In case your ABHA Number is not created, please visit the link (https://healthid.ndhm.gov.in/) to create the same.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Persons to be Insured","fields":[{"help":"Fill details for each person to be insured; total % share cannot exceed 100%","type":"table","label":"Sr. No., Name of the Insured, Nationality, Date of Birth, Age, Gender, Height, Weight, Occupation, Marital Status, Relation with Proposer, ABHA Number","options":[],"required":null,"pdf_field":""},{"help":"Provide appointee details if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee: Name of the Appointee, Date of Birth DD/MM/YYYY, Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Details","fields":[{"help":"","type":"text","label":"Name of Premium payer","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Premium Payment Frequency","options":["Monthly","Quarterly","Half Yearly"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount (in INR)","options":[],"required":null,"pdf_field":""},{"help":"Specify payment instrument","type":"choice","label":"Instrument Type","options":["Cash","Cheque","Debit Card","Credit Card","Others"],"required":null,"pdf_field":""},{"help":"Specify if 'Others' selected","type":"text","label":"Please Specify:","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date (DD/MM/YYYY)","options":[],"required":null,"pdf_field":""},{"help":"If payment by cheque","type":"text","label":"Cheque no.","options":[],"required":false,"pdf_field":""},{"help":"Bank of payment instrument","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Account number for payment","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details","fields":[{"help":"","type":"yes-no","label":"I want related information in - Physical Format","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"e-Format (electronic) as & when applicable","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select one repository","type":"choice","label":"Choose your Insurance Repository (For those selecting e-Format)","options":["NSDL Data Management Ltd.","CDSL Insurance Repository Ltd","Karvy Insurance Repository Ltd.","CAMS Repository Services Ltd"],"required":null,"pdf_field":""},{"help":"Enter e Insurance Account number if available","type":"text","label":"I have e Insurance Account & the No. is","options":[],"required":false,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"My CKYC No. (Central Know Your Customer registry number) is (If available)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/ Existing Health Insurance Details","fields":[{"help":"","type":"text","label":"Policy No./Application No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insurer Name","options":[],"required":false,"pdf_field":""},{"help":"Enter from and to dates","type":"text","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have the same policy from any one or other insurer?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details for Process of Refund","fields":[{"help":"Name as per bank account","type":"text","label":"Name of Accountholder","options":[],"required":null,"pdf_field":""},{"help":"Cheque number if applicable","type":"text","label":"Cheque No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Cheque Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Cheque Amount for INR","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name as in Bank Account","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Account No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign to declare and consent","type":"signature","label":"Signature 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"},{"title":"Agent's Declaration","fields":[{"help":"Agent's full name","type":"text","label":"Full Name","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 Agent","options":[],"required":true,"pdf_field":""},{"help":"Agent license number","type":"text","label":"License Number","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Vernacular Declaration (if applicable)","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of the 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":"Witness must not be advisor/employee","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"},{"title":"Declaration in case the Proposer/Policyholder is Person with Disability (PWD)","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":""}],"filled_by":"proposer and authorized representative"}],"deadlines":[],"applies_to":"Persons with Disability (40% or more certified), Mental Illness, Persons with HIV/AIDS","attachments":["Recent certificate of current CD4 count (within past 30 days) if suffering from HIV/AIDS","Disability certificate mentioning percentage of disability wherever applicable","Copy of Cancelled Cheque for refund bank account"],"declarations":["The statements made in the form are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full receipt of premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical information with government and regulatory authorities.","Awareness of premium loading for habits and diseases declared.","Agreement to keep KYC records of all insured members and provide beneficiary details when required.","Consent to verify identity/address through Central KYC Registry or other portals.","Consent to share medical records with insurer/TPA through ABHA number if available.","Declaration of High Net Worth Individual status if applicable.","Confirmation that premiums are paid from bonafide sources and compliance with AML laws.","Agent declares having explained the form and consequences of untrue statements or non-disclosure.","Witness certifies that the form contents were explained and understood by the proposer.","Proposer with disability authorizes a representative to assist and declare on their behalf."],"dropped_labels":5},"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/5543-medishield-proposal-form"}