{"id":5555,"title":"Compulsory Personal Accident (Owner-Driver) under Motor Insurance Policies 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/Compulsory_Personal_Accident_Owner_Driver_Under_Motor_Insurance_Policies_Proposal_Form_ZK_26_27_v1_17032026_6d646c2b30.pdf","sha256":"9d9c1d7f343e5d8f97e7bd0e7abf65756e09d501080ab6a8b4788cbc00ec9a92","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the proposer (vehicle owner) to apply for compulsory personal accident insurance coverage for the owner-driver under motor insurance policies.","notes":["Fill the form in BLOCK letters only.","Use additional sheets if the insured owns more than one vehicle or if space is insufficient.","Consent to receive calls/communications is valid and overrides NDNC registration unless a Do Not Call form is submitted.","The company is not obliged to issue a policy upon submission of the proposal or payment; acceptance is at the company’s discretion.","If the proposal is not accepted, payment will be refunded without interest.","The sum insured details must be accurate; incorrect information may void the policy ab initio.","Use original documents for KYC and attach copies as required.","The proposer should ensure all mandatory fields marked with * are filled.","The proposer should sign or affix thumb impression after fully understanding the form."],"title":"Compulsory Personal Accident (Owner-Driver) under Motor Insurance Policies Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":"401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. Maharashtra, India"},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"","type":"text","label":"Proposal No.","options":[],"required":null,"pdf_field":""},{"help":"Select the type of vehicle for insurance","type":"choice","label":"Type of Vehicle*","options":["Private Car","Two Wheeler","GCV","PCV","Misc D","New Vehicle","Endorsement","Rollover","Renewal"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Proposal for*","options":[],"required":true,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"Policy Start Date","options":[],"required":null,"pdf_field":""},{"help":"Select time of day","type":"choice","label":"a.m. / p.m.","options":["a.m.","p.m."],"required":null,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"Expiry Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"at midnight","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount in INR","type":"amount","label":"Premium Amount","options":[],"required":null,"pdf_field":""},{"help":"Select type of cover","type":"choice","label":"Type of Cover","options":["Private Car","Two Wheeler","GCV","PCV","Misc D","New Vehicle","Endorsement","Rollover","Renewal"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vehicle / PUC / Licence Details","fields":[{"help":"Vehicle registration number","type":"text","label":"Registration Number","options":[],"required":true,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"End Date","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"Expiry Date","options":[],"required":null,"pdf_field":""},{"help":"Manufacturer of the vehicle","type":"text","label":"Vehicle Make","options":[],"required":null,"pdf_field":""},{"help":"Pollution Under Control certificate start date","type":"date","label":"PUC Period - Start Date","options":[],"required":null,"pdf_field":""},{"help":"Driving license number","type":"text","label":"License Number","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable countries","type":"checkbox","label":"Pick tick if extension of geographical area required?","options":["Bangladesh","Bhutan","Maldives","Nepal","Pakistan","Sri Lanka"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer / Owner’s Details","fields":[{"help":"Full name of the insured","type":"text","label":"1. Title and Name of the Insured*","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address","type":"text","label":"2. Insured Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"First line of address","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Second line of address","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"City or district name","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"Correspondence address if different","type":"text","label":"If Correspondence Address different from Permanent Address, please provide*","options":[],"required":true,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"State name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Country name","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Landline phone number","type":"phone","label":"3. Phone","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"4. Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Valid email address","type":"email","label":"5. Email id*","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"6. Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"7. Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"8. Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"9. Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"Goods and Services Tax Identification Number","type":"text","label":"10. GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Occupation details","type":"text","label":"11. Occupation","options":[],"required":null,"pdf_field":""},{"help":"Profession details","type":"text","label":"12. Profession","options":[],"required":null,"pdf_field":""},{"help":"Select annual income range","type":"choice","label":"13. 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":"Permanent Account Number or Form 60","type":"text","label":"14. PAN* / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":true,"pdf_field":""},{"help":"Central KYC Registry number","type":"text","label":"15. CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""},{"help":"Customer Reference Number or policy number","type":"text","label":"16. Are you an existing Kotak Group Customer, If Yes, Please specify CRN / Zurich Kotak General Insurance Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Employee ID if applicable","type":"text","label":"17. If existing Zurich / Kotak Group Employee, Please specify Employee ID","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Name of the Nominee*","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","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":"Mobile number of nominee","type":"phone","label":"Nominee Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Email address of nominee","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"Current address of nominee","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"Permanent address of nominee","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Bank details for nominee","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"pdf_field":""},{"help":"Percentage share of claim (total must not exceed 100%)","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name and details of appointee 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":"Indicate if you have an Electronic Insurance Account","type":"choice","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if applicable","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":null,"pdf_field":""},{"help":"Email for EIA registration","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you want a new EIA account created","type":"choice","label":"If No, do you want Us to create an EIA account for you (If Yes, please fill up Insurance Repository Application form)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account Number","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":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","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":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"Name of bank or payee","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"Bank and branch details","type":"text","label":"Bank and Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Card payment details","type":"text","label":"For Credit / Debit Card","options":[],"required":null,"pdf_field":""},{"help":"Transaction reference number for card or online payment","type":"text","label":"Transaction Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Date of transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or affix thumb impression","type":"signature","label":"Signature/Thumb impression of Proposer*","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":"proposer"}],"deadlines":[],"applies_to":"Compulsory Personal Accident (Owner-Driver) under Motor Insurance Policies","attachments":["Proof of Identity (POI) and Proof of Address (POA) such as PAN, Ration Card, Passport, Driving Licence, Voter ID Card, Others","Cancelled cheque (if applicable)","Sale Deed","Telephone Bill","List of Electronic Equipment","NCB Reserving Letter","RC Book","Passport","Ration Card","Aadhaar card","Driving License","Payment Advice/Instrument","Renewal Notice / Policy Copy","Fitness Certificate","Valuation Certificate","Vehicle Inspection Report","Voters Identity Card","Electricity Bill"],"declarations":["The statements made in this proposal form are true to the best of the proposer’s knowledge and belief and form the basis of the contract.","Any additions or alterations after submission must be conveyed to the insurer immediately.","The proposal is subject to valid Pollution Under Control (PUC) Certificate/Fitness Certificate and the proposer undertakes to maintain it throughout the policy duration.","The proposer agrees to inform the company immediately of any addition of CNG/PNG kit and obtain necessary endorsement.","Policy and service communications will be sent in soft copy to the email provided unless physical copy is requested.","Consent is given to verify identity/address proof through Central KYC Registry or other government portals for KYC purposes.","The proposer confirms understanding of the proposal form and policy terms and conditions before signing.","If the proposer is a person with disability, they may authorize a representative to act on their behalf.","The proposer may declare as a High Net Worth Individual (HNI) by ticking the box; otherwise, they will not be considered HNI.","All premiums are paid from bonafide sources and not from proceeds of crime; the company may cancel the contract if found otherwise.","The proposer must declare if associated with Politically Exposed Persons (PEP).","Non-profit organizations must declare their status if applicable."],"dropped_labels":1},"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/5555-compulsory-personal-accident-owner-driver-under-motor-insurance-policies-proposa"}