{"id":5558,"title":"Long Term Two Wheeler Secure (Liability Only) - 5 years 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/LTTWS_Liability_Only_5_years_Proposal_Form_ZK_26_27_v1_17032026_c05fa6e9f5.pdf","sha256":"bf7762ddc748c924e583d039823107a07dfcbe86be9cc62b07bbbec3ac5cf107","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase a long term two wheeler liability only insurance policy for 5 years. The proposer (vehicle owner) fills this form.","notes":["Fill the form in BLOCK letters only.","Personal Accident cover for owner driver is compulsory for individual vehicle owners with sum insured of 15 lacs.","Compulsory PA Cover for Owner Drivers cannot be granted if vehicle is owned by a company or similar body corporate.","Total nominee claim share cannot exceed 100%.","If nominee is a minor, details of appointee must be provided.","Use original documents for KYC and attach copies as per the documents list.","Submission of proposal or payment does not oblige the company to issue a policy.","Policy issuance is subject to underwriting and receipt of full premium.","If proposal is not accepted, payment will be refunded without interest.","Consent to receive calls and communications prevails over NDNC registration unless a Do Not Call form is submitted."],"title":"Long Term Two Wheeler Secure (Liability Only) - 5 years Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"","type":"text","label":"Proposal No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Liability Only Policy","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"New Vehicle","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Endorsement","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of cover","options":[],"required":null,"pdf_field":""},{"help":"Fill in BLOCK letters only","type":"text","label":"Proposal for*","options":[],"required":true,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Policy Start Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"a.m. / p.m.","options":["a.m.","p.m."],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Expiry Date for Third Party Liability Section","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"SP Name / Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PoS Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer / Owner’s Details","fields":[{"help":"","type":"text","label":"1. Title and Name of the Insured *","options":[],"required":true,"pdf_field":""},{"help":"Include Address Line 1, Address Line 2, City / District, Pin Code, State, Country","type":"text","label":"2. Insured Permanent Address* (where vehicle is normally kept)","options":[],"required":true,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"3. Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"4. Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"5. Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"6. Occupation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"7. Profession","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"8. Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"9. Email","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"10. GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Include Address Line 1, Address Line 2, City / District, Pin Code, State, Country","type":"text","label":"If Correspondence Address different from Permanent Address, please provide*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"11. 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":"","type":"text","label":"12. PAN* / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"13. CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable documents","type":"checkbox","label":"14. Please share the following for authentication purpose: Proof of Identity (POI) and Proof of Address (POA) [(ü) Tick whichever is applicable]","options":["PAN","Ration Card","Passport","Driving Licence","Voter ID Card","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"15. Are you an existing Kotak Group Customer, If Yes, Please specify CRN / Zurich Kotak General Insurance Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"16. If existing Zurich / Kotak Group Employee, Please specify Employee ID","options":[],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY and a.m./p.m.","type":"date","label":"Proposal Date & Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vehicle Details","fields":[{"help":"","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Invoice Date (For New Vehicle)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Vehicle Make / Model / Variant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Type of body","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Cubic Capacity / kWh (in case of EV)","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Year of Manufacture","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Engine Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Chassis Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Fuel Type","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Color of Vehicle","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration Authority and RTO Location","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Seating Capacity","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Lease / Hire / Hypothecation (Name and address of concerned parties)","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"CNG / LPG / Bi Fuel","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date of Registration","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Inclusion / Exclusion","fields":[{"help":"","type":"yes-no","label":"1. Personal Accident Cover of `15,00,000 for the Owner Driver [GR (36A)]","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"2. Do you wish to include Personal Accident cover for the Named passenger? (IMT 15)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"3. Do you wish to include Personal Accident cover for the Un-named Passengers? (IMT 16)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"4. Do you wish to restrict Third Party Property Damage of Rs. 1 Lakh to the statutory TPPD liability limit of INR 6,000/- only?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide number of persons and CSI opted per person","type":"yes-no","label":"5. Do you wish to cover legal liability? A) Paid Driver/ Cleaner/ Conductor (IMT 28)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide number of persons","type":"yes-no","label":"B) Other Employees (IMT 29)","options":["Yes","No"],"required":null,"pdf_field":""},{"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":"Format DD/MM/YYYY","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Nominee Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Nominee Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nominee Present Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nominee Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"pdf_field":""},{"help":"Total share cannot exceed 100%","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"As per premium cheque for EFT","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":"","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Cancelled cheque submitted of other bank","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"","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":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Cheque Transaction Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Demand Draft","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Credit / Debit Card","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Online Payment","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":null,"pdf_field":""},{"help":"Mandatory","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","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":"Other Information","fields":[{"help":"","type":"checkbox","label":"1. Pick tick if extension of geographical area required? (IMT 1)","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"2. Is the vehicle fitted with fiber glass tank?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"3. Is the vehicle self-owned?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"4. The vehicle belongs to foreign embassy/consulate?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"5. Use of my vehicle is limited to own premise?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"6. Is the vehicle used for Commercial purposes?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, submit proof","type":"yes-no","label":"7. The vehicle is designed for use of Blind / Handicapped / Mentally Challenged persons and duly endorsed as such by RTA?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"8. Are you entitled to No Claim Bonus?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"9. Are you a member of Automobile Association of India (AAI)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes: Association Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Membership Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"10. Do you want Extension for Rally Cover?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"11. Is the vehicle fitted with the any Anti-theft device approved by the ARAI?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date of Expiry","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Driver","fields":[{"help":"Age in years","type":"number","label":"1. Age and Date of Birth : Owner Driver","options":[],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date of Birth Owner Driver","options":[],"required":null,"pdf_field":""},{"help":"If yes, give details","type":"yes-no","label":"2. I or my driver suffer from defective vision or hearing or any physical infirmity?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, give details","type":"yes-no","label":"3. There is a previous history of driving offences (involved / convicted for causing any accident or loss) by me or my drivers:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date of Accident / Loss","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Circumstances of Accident / claim","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Loss / cost `","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Driver's Name","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Format DD MM YYYY","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Long Term Two Wheeler Secure (Liability Only) - 5 years","attachments":["Sale Deed","Pan Card","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","Cancelled cheque"],"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 renewal thereof.","The proposer consents to receive policy and service communications in soft copy via email unless physical copy is requested.","The proposer consents to KYC verification through various government portals.","The proposer confirms understanding of the proposal form and policy terms as explained by the intermediary.","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.","All premiums are paid from bonafide sources and not from proceeds of crime as per AML declaration.","The insurer may cancel the contract if found guilty under money laundering laws.","The proposer must declare if associated with Politically Exposed Persons (PEP).","The proposer must declare if a Non-Profit Organization (if applicable)."],"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/5558-long-term-two-wheeler-secure-liability-only-5-years-proposal-form"}