{"id":5559,"title":"LIABILITY ONLY - 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/Liability_Only_Proposal_Form_ZK_26_27_v1_17032026_b373a23e89.pdf","sha256":"71d8df56e276f28fff07ad09555de61c5c6859262194897f0892f4404799eef4","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for a Liability Only vehicle insurance policy to be filled by the proposer/owner of the vehicle.","notes":["Fill the form in BLOCK letters only.","Attach KYC documents as applicable.","Use original documents where required.","Consent to receive calls/communications will prevail over NDNC registration unless a DNC form is submitted.","Submission of proposal or payment does not oblige the company to issue a policy.","Policy issuance is subject to underwriting policy and receipt of full premium.","If proposal is not accepted, payment will be refunded without interest."],"title":"LIABILITY ONLY - 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. Email: care@zurichkotak.com"},"purpose":"proposal","sections":[{"title":"Policy and Vehicle Details","fields":[{"help":"","type":"text","label":"Proposal No.","options":[],"required":null,"pdf_field":""},{"help":"Select the type of vehicle to be insured","type":"choice","label":"Type of Vehicle*","options":["Misc D","Private Car","Two Wheeler","GCV","PCV"],"required":true,"pdf_field":""},{"help":"Select the type of cover","type":"choice","label":"Type of cover","options":["Proposal for*","Endorsement","Rollover","Renewal"],"required":null,"pdf_field":""},{"help":"Enter date in DD MM YYYY format","type":"date","label":"Policy Start 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":"Vehicle registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Date of invoice if vehicle is new","type":"date","label":"Invoice Date (For New Vehicle)","options":[],"required":false,"pdf_field":""},{"help":"Specify vehicle make, model and variant","type":"text","label":"Vehicle Make / Model / Variant","options":[],"required":null,"pdf_field":""},{"help":"Specify vehicle body type","type":"text","label":"Type of body","options":[],"required":null,"pdf_field":""},{"help":"Engine cubic capacity or kWh for electric vehicles","type":"number","label":"Cubic Capacity / kWh (in case of EV)","options":[],"required":null,"pdf_field":""},{"help":"Year vehicle was manufactured","type":"number","label":"Year of Manufacture","options":[],"required":null,"pdf_field":""},{"help":"Engine number of the vehicle","type":"text","label":"Engine Number","options":[],"required":null,"pdf_field":""},{"help":"Chassis number of the vehicle","type":"text","label":"Chassis Number","options":[],"required":null,"pdf_field":""},{"help":"Color of the vehicle","type":"text","label":"Color of Vehicle","options":[],"required":null,"pdf_field":""},{"help":"Name of registration authority and RTO location","type":"text","label":"Registration Authority and RTO Location","options":[],"required":null,"pdf_field":""},{"help":"Date vehicle was registered","type":"date","label":"Date of Registration","options":[],"required":null,"pdf_field":""},{"help":"Specify if vehicle uses CNG, LPG or Bi Fuel","type":"text","label":"CNG / LPG / Bi Fuel","options":[],"required":null,"pdf_field":""},{"help":"Details of lease, hire or hypothecation parties if applicable","type":"text","label":"Lease / Hire / Hypothecation (Name and address of concerned parties)","options":[],"required":null,"pdf_field":""},{"help":"Number of seats in the vehicle","type":"number","label":"Seating Capacity","options":[],"required":null,"pdf_field":""},{"help":"Gross vehicle weight","type":"number","label":"Gross Vehicle Weight (GVW)","options":[],"required":null,"pdf_field":""},{"help":"Maximum licensed passenger capacity for Passenger Carrying Vehicle","type":"number","label":"Max. licensed carrying capacity (no of passengers) in case of PCV","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer / Owner’s Details","fields":[{"help":"Full name of proposer","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Title: Mr/Ms/Mrs/Others","options":["Mr","Ms","Mrs","Others"],"required":null,"pdf_field":""},{"help":"Permanent address of insured","type":"text","label":"Insured Permanent Address* (where vehicle is normally kept)","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":null,"pdf_field":""},{"help":"Date of birth in DD MM YYYY format","type":"date","label":"Date of Birth*","options":[],"required":true,"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":"Select nationality","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"Occupation of proposer","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"GST Identification Number if applicable","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number or Form 60","type":"text","label":"PAN* / Form 60 (only in case the customer does not have PAN No.)","options":[],"required":true,"pdf_field":""},{"help":"Central KYC identifier if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Select applicable identity and address proofs","type":"checkbox","label":"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":"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":"Profession of proposer","type":"text","label":"Profession","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Employee ID if applicable","type":"text","label":"If existing Zurich / Kotak Group Employee, Please specify Employee ID","options":[],"required":false,"pdf_field":""},{"help":"Choose if you want policy copy by email","type":"yes-no","label":"Would you like to opt for soft copy of policy","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you are an existing customer","type":"yes-no","label":"Are you an existing Kotak Group customer?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Customer reference number or policy number","type":"text","label":"If Yes, Please specify CRN / Zurich Kotak General Insurance Policy No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vehicle Insurance History","fields":[{"help":"Name and address of previous insurer","type":"text","label":"Name and Address of Previous Insurer*","options":[],"required":true,"pdf_field":""},{"help":"Select previous policy type","type":"choice","label":"Previous Policy Type*","options":["Package Cover","Liability only","Others"],"required":true,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Previous Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Start and end dates of previous insurance","type":"date","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any claims were made","type":"yes-no","label":"Have you made any claim in the previous expiring policy?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide year, number of claims, and claim amount for last 3 years","type":"table","label":"If yes, please provide details for 3 years (year, no. of claims, claim amount (₹))","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Inclusion / Exclusion","fields":[{"help":"Select if you want PA cover for named passenger","type":"yes-no","label":"Do you wish to include Personal Accident cover for the Named passenger? (IMT 15)*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select if you want PA cover for unnamed passengers","type":"yes-no","label":"Do you wish to include Personal Accident cover for the Un-named Passengers? (IMT 16)*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select if you want to restrict TPPD limit","type":"yes-no","label":"Do you wish to restrict Third Party Property Damage to statutory TPPD liability limit?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you want to cover legal liability for paid driver/cleaner/conductor","type":"yes-no","label":"Do you wish to cover legal liability? A) Paid Driver/ Cleaner/ Conductor (IMT 28)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Policy tenure in years","type":"number","label":"Tenure (years)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee 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":false,"pdf_field":""},{"help":"Email ID of nominee","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Present address of nominee","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"Permanent address of nominee","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Bank details of nominee","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim for nominee","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":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Information","fields":[{"help":"Select if extension of geographical area is required","type":"yes-no","label":"Extension of geographical area required? (IMT 1)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle has fiber glass tank","type":"yes-no","label":"Is the vehicle fitted with fiber glass tank?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle is self-owned","type":"yes-no","label":"Is the vehicle self-owned?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle belongs to foreign embassy or consulate","type":"yes-no","label":"The vehicle belongs to foreign embassy/consulate?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle use is limited to own premises","type":"yes-no","label":"Use of my vehicle is limited to own premise?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle is used commercially","type":"yes-no","label":"Is the vehicle used for Commercial purposes?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle is used for driving tuition","type":"yes-no","label":"Is the vehicle used for driving tuition?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if vehicle is designed for disabled persons","type":"yes-no","label":"The vehicle is designed for use of Blind / Handicapped / Mentally Challenged persons and duly endorsed as such by RTA?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if entitled to No Claim Bonus","type":"yes-no","label":"Are you entitled to No Claim Bonus?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if member of AAI","type":"yes-no","label":"Are you a member of Automobile Association of India (AAI)?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Name of association if member","type":"text","label":"If Yes: Association Name","options":[],"required":false,"pdf_field":""},{"help":"Membership number if member","type":"text","label":"Membership Number","options":[],"required":false,"pdf_field":""},{"help":"Select if extension for rally cover is required","type":"yes-no","label":"Do you want Extension for Rally Cover?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Expiry date of any relevant document","type":"date","label":"Date of Expiry","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Bank account number for premium refund or payment","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":"Cheque or demand draft number if payment made by these modes","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Name of bank branch cheque/DD is drawn to","type":"text","label":"Drawn To","options":[],"required":false,"pdf_field":""},{"help":"Bank and branch name for cheque/DD","type":"text","label":"Bank and Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Transaction reference number for card payments","type":"text","label":"For Credit / Debit Card Transaction Reference No","options":[],"required":false,"pdf_field":""},{"help":"Date of payment transaction","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Amount drawn in payment","type":"amount","label":"Drawn Amount","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details","fields":[{"help":"Indicate if you have an Electronic Insurance Account","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Email ID for EIA registration","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Select if you want the insurer to create an EIA account","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Driver","fields":[{"help":"Age of owner driver","type":"number","label":"Age and Date of Birth : Owner Driver","options":[],"required":null,"pdf_field":""},{"help":"Indicate if any physical infirmity","type":"yes-no","label":"I or my driver suffer from defective vision or hearing or any physical infirmity?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of infirmity","type":"text","label":"If yes please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any driving offences","type":"yes-no","label":"There is a previous history of driving offences (involved / convicted for causing any accident of loss) by me or my drivers:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Details of driving offences","type":"text","label":"If yes please give details","options":[],"required":false,"pdf_field":""},{"help":"Name of driver involved in accident/claim","type":"text","label":"Driver's Name","options":[],"required":false,"pdf_field":""},{"help":"Date of accident or loss","type":"date","label":"Date of Accident Loss","options":[],"required":false,"pdf_field":""},{"help":"Description of accident or claim circumstances","type":"text","label":"Circumstances of Accident / claim","options":[],"required":false,"pdf_field":""},{"help":"Amount of loss or claim cost","type":"amount","label":"Loss / cost ₹","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signature","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":"Liability Only Policy for Private Car, Two Wheeler, Goods Carrying Vehicle (GCV), Passenger Carrying Vehicle (PCV), Misc D","attachments":["Proposal Form","GST Exemption","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"],"declarations":["The statements made in this Proposal Form are true to the best of the proposer’s knowledge and belief.","Any additions or alterations after submission will 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 unless physical copy is requested.","Consent is given to verify identity/address through Central KYC Registry or other government portals.","The proposer has understood the contents of the proposal form and policy terms and conditions.","If proposer is a person with disability, they authorize a representative to act on their behalf.","The proposer confirms payment of premiums from bonafide sources and compliance with AML regulations.","The proposer declares if they qualify as a High Net Worth Individual (HNI).","Prohibition of rebates under Section 41 of Insurance Act 1938 is acknowledged."],"dropped_labels":9},"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/5559-liability-only-proposal-form"}