{"id":5545,"title":"Maxima Directors and Officers 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/MDOLI_Praposal_Form_ZK_v2_24_25_13122024_5b78ecd361.pdf","sha256":"46b7f7655e0b171b6dce3cb89d9d7f4c4a2cd3b7a099e06b4f441e829f3d7e3f","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Directors and Officers Liability Insurance to be filled by the company seeking insurance coverage for its directors and officers.","notes":["Answer all questions legibly and to the best of your knowledge.","If insufficient space, provide additional information on separate sheet.","Mark Not Applicable (N/A) where sections do not apply.","Submission of proposal or payment does not guarantee policy issuance.","Policy liability starts only after acceptance and premium receipt.","Use attachments for subsidiary list and claims details if needed.","Email ID is mandatory for Electronic Insurance Account details.","Total % share of nominee claim cannot exceed 100%.","Original documents may be required for verification.","Signatures and dates are mandatory in declaration sections."],"title":"Maxima Directors and Officers Liability Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of the Proposed Insured’s Company","fields":[{"help":"Enter the full legal name of the company","type":"text","label":"Name of the company or organisation","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the head office","type":"text","label":"Head office Address","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when the company started business","type":"date","label":"Date the Company started its business","options":[],"required":null,"pdf_field":""},{"help":"Describe the main business operations and activities","type":"text","label":"Description of business operations and activities","options":[],"required":null,"pdf_field":""},{"help":"Enter the country where the company is registered","type":"text","label":"Country of Registration","options":[],"required":null,"pdf_field":""},{"help":"Enter the company website URL if available","type":"text","label":"Website Address","options":[],"required":false,"pdf_field":""},{"help":"Attach a separate sheet with subsidiary details","type":"attachment","label":"Give a complete list of all subsidiary companies not listed in the company’s last annual report, including country of registration and percentage owned by Proposer","options":[],"required":null,"pdf_field":""},{"help":"Select the appropriate company type","type":"choice","label":"Is the Company? a. Private b. Publicly Listed c. Government owned d. Not for Profit e. Others: Please describe","options":["Private","Publicly Listed","Government owned","Not for Profit","Others"],"required":null,"pdf_field":""},{"help":"Provide listing details if applicable","type":"text","label":"If Publicly Listed, please provide the details of the stock exchanges where the Company or its Subsidiaries are listed below: Country of Listing, Date of Listing, Amount Raised (Please provide currency details)","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Communication Address same as the Head Office Address","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Insurance History","fields":[{"help":"Name of current D&O insurer if any","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""},{"help":"Enter policy period dates","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Enter policy limit amount","type":"amount","label":"Policy Limit","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium","options":[],"required":null,"pdf_field":""},{"help":"Enter deductible amount","type":"amount","label":"Deductible","options":[],"required":null,"pdf_field":""},{"help":"Specify territory and jurisdiction covered","type":"text","label":"Territory and Jurisdiction","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company or any directors and officers ever had entitlement to indemnity under any insurance policy denied or otherwise affected due to non disclosure, fraud, misrepresentation or breach of a policy provision?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company or any proposed Insured Person ever been refused this type of insurance or had similar insurance cancelled or had an application of renewal declined or had special terms imposed?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Enter desired policy period","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Enter retroactive date if applicable","type":"date","label":"Retroactive Date","options":[],"required":null,"pdf_field":""},{"help":"Select territory option","type":"choice","label":"Territory","options":["India","Worldwide excluding USA and Canada","Worldwide including USA and Canada"],"required":null,"pdf_field":""},{"help":"Select jurisdiction option","type":"choice","label":"Jurisdiction","options":["India","Worldwide excluding USA and Canada","Worldwide including USA and Canada"],"required":null,"pdf_field":""},{"help":"Provide details of other coverages if any","type":"text","label":"Any other coverages to be added as a separate request to be duly signed and stamped","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Claims History","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Has there been or is pending now any claim against any directors or officers in their capacity as a director or officer of the Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach details of claims if applicable","type":"attachment","label":"If yes, please provide more details in a separate sheet (if required) about the claim including the claimant, current status of the claim, amounts paid and insurer reserve amounts","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Company or its directors or officers aware of any circumstances, incidents that might lead to a claim being made against any director or officer in their capacity as a director or officer of the Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have any of the Company’s principals, partners, directors, officers or employees ever been the subject of any disciplinary proceeding, prosecution, been fined or penalized or been subject of any inquiry or investigation in their capacity as a director or officer of the Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Employee Details","fields":[{"help":"Enter total number of employees","type":"number","label":"Total Number of Employees","options":[],"required":null,"pdf_field":""},{"help":"Fill employee numbers and wage roll by region and category","type":"table","label":"Break-up of Employees: Description of Employees* (USA/Canada/Australia, UK/Europe, Rest of the World, India) No. and Wage Roll for C-suite Employees, Directors, Managerial Positions, All other employees","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company maintain a written manual of its human resource procedures?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have a written policy against discrimination including sexual harassment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Mergers and Acquisitions","fields":[{"help":"Select Yes or No","type":"yes-no","label":"During the last 3 years, has the following transpired in the Company? The name, logo or trademark of the Company changed?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Capital structure of the Company changed?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Any subsidiary of the Company been sold or ceased trading?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If the answer to any of the above questions is Yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company made or is aware of any proposed acquisitions, tender offers or mergers pending or under consideration?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Financial Position and Internal Controls","fields":[{"help":"Attach financial statements","type":"attachment","label":"Please attach Financial Statements for the previous 2 financial years","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is there any proposed Insured Person aware of facts or circumstances that might affect the ability of the Company to meet all its debt requirements as and when they fall due?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If no, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company changed its external auditor in the last 3 years or intending to change their external auditor in the next 12 months?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Within the last 12 months has the Company’s external auditors stated that there are any significant weaknesses in the Company’s internal system control and governance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Within the previous 3 years has the Company has any disputes with its external auditors regarding internal treatment of financial information?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are any of the Company’s significant accounting practices, including revenue recognition among others, expected to change in the next 12 months?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have all the revenue recognition practices used by the Company been approved by the external auditor?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company ever re-stated its financial results or is it intending to re-state its financial results in the next 12 months?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Since the date of the last Financial Statement attached to this proposal, have there been any material developments which have adversely impacted the financial position of the Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Within the last 12 months have there been any changes to the board members or structure of the Company’s Board?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Shareholder Information and Corporate Governance","fields":[{"help":"Enter total ordinary shares","type":"number","label":"What is the total number of ordinary shares outstanding in the Company?","options":[],"required":null,"pdf_field":""},{"help":"Enter total number of shareholders","type":"number","label":"What is the total number of shareholders in the Company?","options":[],"required":null,"pdf_field":""},{"help":"Enter shares held by directors","type":"number","label":"What is the total number of shares held by directors of the Company?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of major shareholders","type":"text","label":"Please list all the shareholders who control more than 10% of the Company’s voting share capital and the percentage of shares held by those shareholders","options":[],"required":null,"pdf_field":""},{"help":"List stock exchanges if applicable","type":"text","label":"On which stock exchanges are the Company’s shares traded?","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have on issue any securities which are convertible into shares?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Company a subsidiary of another company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company listed on a Stock Exchange comply with the required Corporate Governance Standards and/or best practices concerning corporate governance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If no, please provide more details regarding which recommendations are not met and why","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has the Company ever been questioned by regulators regarding their continuous disclosure obligations?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have in place policies concerning the trading in company securities by its directors or officers?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the same","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"USA Exposures","fields":[{"help":"Enter total gross assets in USA","type":"amount","label":"What are the total gross assets the Company has in the USA?","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have any subsidiaries in the USA?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of USA subsidiaries","type":"text","label":"If yes, please list these Subsidiaries and their business operations","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have any interest in any USA based businesses or organisations?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details regarding the entity’s name and the Company’s equity interest in the USA based entity","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company or any of its subsidiaries have any USA securities listings?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide details regarding the same","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have any American Depository Receipts (ADRs) traded in the USA?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide ADR programme details","type":"text","label":"If yes, please provide the following details regarding the same: a. What is the level of the ADR programme (I, II, III, or s144)? b. How many ADR’s are currently on issue? c. What was the commencement date of the ADR programme? d. List the 3 largest holders of ADR’s and their respective shareholdings","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company’s internal audit committee structure and/or procedures comply with U.S. statutes, rules or regulations regarding internal audit committees?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide reasons if no compliance","type":"text","label":"If no, please provide the reasons why there is no compliance","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are the Company’s financial statements required to be consolidated, or reconciled, in accordance with US Generally Accepted Accounting Principles (GAAP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If “Yes,” are the company’s financial statements, generally, in accordance with US GAAP?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the U.S. SEC or U.S. IRS presently investigation or requesting information from the Company or any director or officer of the Company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please provide more details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured company"},{"title":"Other Important Information","fields":[{"help":"Enter GSTIN number if applicable","type":"text","label":"GSTIN Number","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN or attach Form 60 if no PAN","type":"text","label":"For Individual customers, please share below details: PAN* / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":null,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Salaried","Professionals","Student","Housewife","Retired","Others"],"required":false,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":null,"pdf_field":""},{"help":"Select annual income range","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":"Enter CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable identity and address proofs","type":"checkbox","label":"Please share the following for authentication purpose: Proof of Identity (POI) and Proof of Address (POA) [(ü) Tick whichever is applicable]","options":["PAN","Aadhaar","Passport","Driving Licence","Voter ID Card","Others"],"required":null,"pdf_field":""},{"help":"Enter PAN and GSTIN for corporate customers","type":"text","label":"For Corporate customers, please share below details: PAN*, GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Enter authorised signatory details","type":"text","label":"Please share the below details for the Authorised Signatory: Name, Designation, CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposed insured company or individual"},{"title":"Payment and Acknowledgement","fields":[{"help":"Enter amount received","type":"amount","label":"Received from Ms./Mrs./ Mr a sum of `","options":[],"required":null,"pdf_field":""},{"help":"Specify payment mode","type":"text","label":"Through Cheque/DD against your proposal for Maxima Directors and Officers Liability Insurance","options":[],"required":null,"pdf_field":""},{"help":"Signature of company official or intermediary","type":"signature","label":"Signature of Zurich Kotak General Insurance Company (India) Limited Official / Intermediary","options":[],"required":null,"pdf_field":""},{"help":"Date of receipt","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of official or intermediary","type":"text","label":"Zurich Kotak General Insurance Company (India) Limited Official/Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"Tick if cancelled cheque submitted","type":"checkbox","label":"Details as per premium cheque to be used for electronic fund transfer; Cancelled cheque submitted of other bank","options":["Cancelled cheque submitted"],"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 name","type":"text","label":"Account Holder name","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter EIA number if applicable","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Enter insurance repository name","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","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":"Enter registered email id","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Note about address override","type":"text","label":"Your address details as mentioned in the EIA account shall override the address provided in this application for Insurance","options":[],"required":false,"pdf_field":""}],"filled_by":"proposed insured or intermediary"},{"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":"Enter relationship","type":"text","label":"Relationship of Nominee with Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter email id","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter present address","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Enter permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Enter 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: Name of the Appointee, Date of Birth DD/MM/YYYY, Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Signature of proposer","type":"signature","label":"Signature of 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":"Enter authorised signatory details and affix company stamp","type":"text","label":"Authorised Signatory, Company Stamp, Position in Your Company","options":[],"required":true,"pdf_field":""},{"help":"Select organisation type","type":"choice","label":"Type of Organisation making the payment","options":["Limited Company","International Organisation","Trust","Partnership","Section 25 Company","Non-Government Organisation (NGO)","Society","Others","Government Organisation","Co-operatives"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are You or any of the proposed applicants or close relatives associated to Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you a Non-Profit Organization? (only in case of an entity)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name of authorized representative and declaration","type":"text","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":false,"pdf_field":""},{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of 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":""}],"filled_by":"proposer and intermediary"},{"title":"Vernacular Declaration and Prohibition of Rebates","fields":[{"help":"Agree to vernacular declaration","type":"checkbox","label":"Vernacular Declaration","options":["I hereby declare that, I have fully explained the contents of the proposal form and terms and conditions of the Policy to the Proposer in the language understood to him/her and that the Proposer has affixed the thumb impression / signature after fully understanding the contents thereof."],"required":true,"pdf_field":""},{"help":"Acknowledgement of rebate prohibition","type":"text","label":"Prohibition of Rebates (Under Section 41 of Insurance Act 1938)","options":[],"required":true,"pdf_field":""},{"help":"Signature and stamp of insurance advisor or agent","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":"Signature of proposer","type":"signature","label":"Signature of 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":""}],"filled_by":"intermediary and proposer"}],"deadlines":[],"applies_to":"Directors and Officers Liability Insurance for companies and their subsidiaries","attachments":["Complete list of all subsidiary companies not listed in the company’s last annual report","Financial Statements for the previous 2 financial years","Details of claims if applicable"],"declarations":["All information given is true to the best of knowledge and non-disclosure of material facts may void the policy.","Consent to receive policy and service communication in soft copy.","Consent to verify identity/address through government portals for KYC.","Declaration of High Net Worth Individual status if applicable.","AML declaration confirming premiums paid from bonafide sources.","Acknowledgement of prohibition of rebates under Section 41 of Insurance Act 1938.","Vernacular declaration confirming explanation of form contents in understood language."],"dropped_labels":10},"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/5545-maxima-directors-and-officers-liability-insurance-proposal-form"}