{"id":5544,"title":"Maxima Public Liability 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/Maxima_Public_Liability_Insurance_Proposal_Form_ZK_V2_24_25_13122024_620b308a82.pdf","sha256":"182aac15229726ddc2587cbf972c7abcef81558ed04c5aed4cf2715cb2421ef5","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (individual or corporate) to apply for Maxima Public Liability Insurance coverage by providing detailed information about their business, premises, employees, prior insurance, and other relevant details.","notes":["Answer all questions fully and correctly; if not applicable, mark as N.A.","Use additional sheets if space is insufficient to provide details.","Original documents or copies may be required for verification.","Policy liability starts only after acceptance of proposal and receipt of premium.","Use block letters where applicable.","Total nominee claim share cannot exceed 100%.","Email ID is mandatory for Electronic Insurance Account details.","The form includes a prohibition of rebates as per Section 41 of Insurance Act 1938."],"title":"Maxima Public Liability Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Section I: General Information","fields":[{"help":"","type":"text","label":"Name & Registered Address of the Proposer (including names of all subsidiaries or affiliated companies to be insured)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Website Address, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Please describe your business operations and activities","options":[],"required":null,"pdf_field":""},{"help":"Specify duration in years or months","type":"text","label":"Length of time in business","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you require any cover for any subsidiary, affiliate or representative outside India? If yes, please fill up Annexure A attached to the Proposal Form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is the Communication Address same as the Registered Address","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if communication address differs from registered address","type":"text","label":"Communication Address","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section II: Insurance Requirement","fields":[{"help":"Enter amount in Indian Rupees","type":"amount","label":"Limits of Insurance (Amount in Indian Rupees) : Any One Accident (AOA)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Indian Rupees","type":"amount","label":"Limits of Insurance (Amount in Indian Rupees) : Any One Year (AOY)","options":[],"required":null,"pdf_field":""},{"help":"Specify start and end dates or duration","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Date from which coverage is effective retrospectively","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Territory","options":["India","Worldwide excluding USA and Canada","Worldwide including USA and Canada"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Jurisdiction","options":["India","Worldwide excluding USA and Canada","Worldwide including USA and Canada"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section III: General Liability","fields":[{"help":"","type":"text","label":"Please give full description of activities for which cover is required","options":[],"required":null,"pdf_field":""},{"help":"Columns: Location, Manufacturing Units (No. of locations, Nature of Risk), Warehouses/Godowns/Shops/Depots/Tank Farms/Offices (No. of locations, Nature of Risk)","type":"table","label":"List all premises to be insured in India: Please also include Guest Houses, Pipelines outside the plants, Head Offices and Regional Offices etc.","options":[],"required":null,"pdf_field":""},{"help":"Columns: Year, Premises, Operations, Projected, Current, Last Year","type":"table","label":"Please quantify annual sales turnover of last three years (Amount in Indian Rupees)","options":[],"required":null,"pdf_field":""},{"help":"Columns: Manufacturing Unit, North, East, South, West","type":"table","label":"Please describe in brief surrounding areas and third party property within an approximate radius of 2 kms from each manufacturing unit","options":["Industrial Area","Agricultural Area","Residential Area","Others"],"required":null,"pdf_field":""},{"help":"Attach layout plans and risk inspection reports if available","type":"attachment","label":"Please attach Lay-Out Plans and Risk Inspection Report (if available) of the manufacturing units proposed for Insurance","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Do you handle or use gases, pressure-storage, explosive, hazardous substances, asbestos, toxic, radioactive materials and hydrocarbons? If so, please give details of their quantity, storage, handling and precautions taken","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Will you, or your employees, handle or come into contact with any industrial dust of known harmful nature (e.g. asbestos, silica, cotton), radioactive materials, or any other substance harmful to health?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick all extensions required and provide details where requested","type":"checkbox","label":"Extensions required","options":["Act of God Perils Extension (viz., Earthquake, Storm, Typhoon, Flood and Inundation etc.)","72 Hrs Sudden and Accidental Pollution Extension","Transportation Cover – Please indicate the materials for which this cover is desired that will be transported by you during the Proposed Policy period","Terrorism Cover"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name and Registered Address of Additional Insured, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Will you require Waiver of Subrogation for the above Additional Insured?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"List up to five designated members","type":"text","label":"Do you require a Group Control Clause – Please indicate the designated members of the above Group (no more than five) who will have the ultimate responsibility for Insurance Claims in your organisation","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Effluent Discharge Extension","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide length if Effluent Discharge Extension is selected","type":"text","label":"If yes, what is the length of pipeline from the compound wall of your premises to the disposal point?","options":[],"required":false,"pdf_field":""},{"help":"Describe fire prevention program if any","type":"text","label":"Is there a programme for the prevention of fire, explosion incidents? If so, please indicate:","options":[],"required":false,"pdf_field":""},{"help":"Specify type of detection and alarm system","type":"text","label":"Type of detection and alarm system","options":[],"required":false,"pdf_field":""},{"help":"Provide details of service organizations available","type":"text","label":"Availability of service organisation in case of such incidents (fire brigade, specialists in environmental protection and toxicology)","options":[],"required":false,"pdf_field":""},{"help":"Describe emergency provisions","type":"text","label":"Provisions made for supply of energy, water etc. in an emergency","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section IV: Do You Require Coverage for Pollution","fields":[{"help":"","type":"yes-no","label":"Are any of your plants or premises situated in vulnerable water protection zone or water conservation areas?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of waste treatment and control systems","type":"text","label":"Please give details of Treatment/Disposal and Control systems for solid, liquid and gaseous waste or effluents","options":[],"required":null,"pdf_field":""},{"help":"Attach latest consent letter if yes","type":"yes-no","label":"Whether the plant has the consent of the Pollution Control Board (copy of the latest consent letter should be attached)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether emission from all stocks are periodically measured as per Pollution Control Board's requirement and percentage of various constituents are logged","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether all effluent systems are analysed for its constituents as per Pollution Control Board requirements and are logged?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether the plant has been sanctioned consent for liquid and gas phased dischargers by the Pollution Control Board","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section V: Employee Details","fields":[{"help":"Columns: Description of Employees, USA/Canada/Australia (No., Wage Roll), UK/Europe (No., Wage Roll), Rest of the World (No., Wage Roll), India (No., Wage Roll). Descriptions: Clerical Staff, Supervisory/Manual, Hazardous Activity (specify), All other employees","type":"table","label":"Please provide projected details for the next 12 months","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section VI: Loss Information","fields":[{"help":"Columns: Date of Occurrence, Description of Claim, Date of Claim, Amount Paid, Amount Reserved, Claim Status (Open/Closed)","type":"table","label":"Please enter all claims or losses (regardless of fault and whether or not insured) or any occurrences or incidents, conditions, defects, circumstances or suspected defects, which may give rise to a claim; over the last five years under Public Liability and/or Products Liability (Amount in Indian Rupees)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section VII: Prior Insurance","fields":[{"help":"Columns: Type, Insurer, Limit of Liability, Premium (excluding taxes and ERF contribution), Deductible. Types include Public Liability Act, Public Liability, Product Liability, Commercial General Liability","type":"table","label":"Please provide details of expiring policy","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Retroactive Date in the expiring policy","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section VIII: Additional Details","fields":[{"help":"","type":"choice","label":"Nationality","options":["Indian","Non – Indian"],"required":true,"pdf_field":""},{"help":"Fill only if nationality is Non-Indian","type":"text","label":"If Non-Indian, please specify Country","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Type of Organization","options":["Corporations","Governments","Non Governmental Organizations","Society","International Organization","Trust","Partnership","Cooperatives","Section 25 Company"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section IX: Other Information","fields":[{"help":"","type":"text","label":"GSTIN Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Sources of funds","options":["Salary","Business","Investments","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Provide PAN or Form 60 if no PAN","type":"text","label":"PAN / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Occupation","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Nationality","options":["Indian","Non-Indian","NRI"],"required":null,"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":null,"pdf_field":""},{"help":"For authentication purpose","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable documents and specify if Others","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":null,"pdf_field":""},{"help":"","type":"text","label":"For Corporate customers, please share below details: PAN","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"For Corporate customers, please share below details: GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"For the Authorised Signatory: Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details and Electronic Insurance Account","fields":[{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Account Holder name","options":[],"required":null,"pdf_field":""},{"help":"Cheque or Demand Draft number","type":"text","label":"Cheque / D.D#","options":[],"required":null,"pdf_field":""},{"help":"Name of bank or branch on cheque/DD","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank and Branch Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"For Credit / Debit Card: Transaction Reference No","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if EIA account exists","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Name of insurance repository if EIA account exists","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":false,"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":"Mandatory for EIA account","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details (Applicable for individual customers)","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":"Date of birth of nominee","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":"Fill if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee: Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Date of birth of appointee","type":"date","label":"Where Nominee is a minor, give details of Appointee: Date of Birth DD/MM/YYYY","options":[],"required":false,"pdf_field":""},{"help":"Relationship of appointee to nominee","type":"text","label":"Where Nominee is a minor, give details of Appointee: Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"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":""},{"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":"Agent declares explanation of policy features and terms to proposer","type":"text","label":"Declaration for Agent","options":[],"required":true,"pdf_field":""},{"help":"Declaration that contents were explained in language understood by proposer","type":"text","label":"Vernacular Declaration","options":[],"required":true,"pdf_field":""},{"help":"Proposer declares all information is true and complete","type":"text","label":"Declaration (In respect of all sections)","options":[],"required":true,"pdf_field":""},{"help":"Declaration regarding source of premiums and compliance with anti-money laundering laws","type":"text","label":"AML Declaration","options":[],"required":true,"pdf_field":""},{"help":"Authorization of representative to assist proposer with disability","type":"text","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Public Liability Insurance policies","attachments":["Lay-Out Plans and Risk Inspection Report (if available) of the manufacturing units proposed for Insurance","Copy of the latest consent letter from Pollution Control Board (if applicable)","Proof of Identity (POI) and Proof of Address (POA) documents as applicable","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["The proposer must disclose all material facts and not suppress any information relevant to the risk.","Failure to disclose material facts may result in claim rejection or policy avoidance.","The company is not obliged to accept the proposal or issue a policy upon receipt of the form or payment.","Premium must be received in full and in time for the policy to be effective.","All information provided is true to the best of the proposer's knowledge and any false or misleading information will void the policy.","Premiums have been/will be paid from bonafide sources and not from proceeds of crime.","The proposer consents to verification of identity and address through official registries.","The proposer declares whether they are a politically exposed person or a non-profit organization as applicable.","If the proposer is a person with disability, they may authorize a representative to assist in completing the form."],"dropped_labels":3},"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/5544-maxima-public-liability-insurance-proposal-form"}