{"id":5546,"title":"Plate Glass Insurance Proposal Form & Questionnaire","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Plate_Glass_Insurance_Proposal_Form_ZK_V2_24_25_13122024_f189e68a41.pdf","sha256":"4089c0caee3286de24bf744421d30088788afdcd7ee38d996d51e5342fc98d93","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or corporate proposers to apply for plate glass insurance coverage by providing details about themselves, the glass to be insured, and related risk information.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","All information will be treated in strict confidence.","Policy issuance is at the sole discretion of the company and subject to underwriting policy and premium receipt.","Policy and service communications will be sent in soft copy to the email provided unless physical copy is requested.","Use original documents for proofs and payments.","Total nominee share percentage must not exceed 100%."],"title":"Plate Glass Insurance Proposal Form & Questionnaire","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":"Describe the trade or business of the proposer","type":"text","label":"Proposer's Trade or Business*","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid contact number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 1","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Enter address line 2","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Enter city or district","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"Provide registered or permanent address","type":"text","label":"Registered Office Address / Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Tick 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 postal address if different","type":"text","label":"Communication (Postal) Address*","options":[],"required":true,"pdf_field":""},{"help":"Provide nearest landmark to the address","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter country","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Provide valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide GSTIN or Form 60 if no PAN","type":"text","label":"GSTIN / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN number","type":"text","label":"PAN*","options":[],"required":true,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":null,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"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":null,"pdf_field":""},{"help":"Provide CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Corporate Customer Details","fields":[{"help":"Provide corporate PAN","type":"text","label":"PAN*","options":[],"required":true,"pdf_field":""},{"help":"Provide corporate GSTIN","type":"text","label":"GSTIN*","options":[],"required":true,"pdf_field":""},{"help":"Name of authorised signatory","type":"text","label":"Authorised Signatory Name","options":[],"required":null,"pdf_field":""},{"help":"Designation of authorised signatory","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Provide CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""},{"help":"Nearest landmark to address","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"State of address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Country of address","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Address line 1","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Address line 2","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"City or district","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Particulars of Glass to be Insured","fields":[{"help":"Specify location of the glass to be insured","type":"text","label":"Location of glass","options":[],"required":null,"pdf_field":""},{"help":"Provide dimensions of the glass","type":"text","label":"Dimensions of Plate Glass","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured amount in INR","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Details","fields":[{"help":"Enter indemnity amount in INR","type":"amount","label":"Amount of Indemnity required (Sum Insured): In respect of loss of or damage to the Plate Glass? INR","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no for terrorism damage cover","type":"yes-no","label":"Please specify if you wish to opt for additional cover Terrorism Damage Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide address of premises","type":"text","label":"Address of the Premises containing glass to be insured","options":[],"required":null,"pdf_field":""},{"help":"Describe any broken or damaged glass","type":"text","label":"Is there at present any broken or damaged glass? If so, describe its position and size","options":[],"required":null,"pdf_field":""},{"help":"Specify details of any glass not included","type":"text","label":"Is there any glass in the premises not included in the Schedule? If so, specify details","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Would you like to cover all Fixed plate glass of your premises","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe if premises are at corner or special risk","type":"text","label":"Are the premises situated at the corner of a street or exposed to any special risk","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any claims in last 5 years","type":"text","label":"Have any claims been made against you in the last five years in respect of accidents caused directly or indirectly by the Plate Glass. If so, give full particulars.","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any company declined, cancelled or accepted on special terms","type":"text","label":"Has any Company: (a) Declined your Proposal? (b) Cancelled or refused to renew your Policy? (c) Accepted your Proposal on special terms and condition?","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":""}],"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":"Provide nominee's mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Provide nominee's email address","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Provide nominee's bank details","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":null,"pdf_field":""},{"help":"Name of insurance repository","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide email registered with insurance repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign or stamp the form","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":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"Enter amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Name of bank or entity cheque/DD is drawn to","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Name of bank and branch","type":"text","label":"Bank and Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction reference number","type":"text","label":"For Credit/Debit Card: Transaction Reference No","options":[],"required":null,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Refund / Claims Detail","fields":[{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Account Holder name","options":[],"required":null,"pdf_field":""},{"help":"Tick if cancelled cheque from other bank is submitted","type":"checkbox","label":"Cancelled cheque submitted of other bank","options":["Yes"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration","fields":[{"help":"Proposer's signature or thumb impression","type":"signature","label":"Signature / Stamp of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary / Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Declaration in case the proposer/policyholder is person with disability (PWD)","fields":[{"help":"Signature or thumb impression of proposer","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Plate Glass Insurance","attachments":["Additional sheets if more space is needed to answer questions","Proof of Identity and Proof of Address documents","Cancelled cheque for refund/claims bank details","Insurance Repository Application form (if opting for EIA account creation)"],"declarations":["The statements made in this proposal form are true, complete and form the basis of the insurance policy.","The company’s liability starts only after acceptance of the proposal and receipt of premium.","The policy can be voided if any information is untrue, incorrect, incomplete or withheld.","Consent is given to verify identity/address through government portals for KYC.","Premiums are paid from bonafide sources and not from proceeds of crime under the Prevention of Money Laundering Act.","The proposer may be classified as a High Net Worth Individual only if declared.","No rebates are allowed as inducements under Section 41 of the Insurance Act 1938.","The proposer confirms understanding of policy features and terms as explained by the agent.","If the proposer is a person with disability, an authorized representative may 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/5546-plate-glass-insurance-proposal-form-and-questionnaire"}