{"id":5564,"title":"Group Smart Health - Micro 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/Group_Smart_Health_Micro_Insurance_Proposal_Form_ZK_V1_25_26_11082025_55c0155592.pdf","sha256":"f032122652b619c678a14c55d58afc53cc0ebdf6ef43ad02cefb2f81fbfd7ba3","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (policyholder or group administrator) to apply for the Group Smart Health - Micro Insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, coverage, benefit, insured, nominee, and payment details for insurance underwriting.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Use original documents and provide accurate information.","Online or credit card payments must be made by the policyholder only; third party payments are not allowed.","If additional space is needed, attach extra sheets referencing the question number.","Total claim share percentage among nominees must not exceed 100%.","The issuance of this form does not mean acceptance of the proposal; policy liability starts only after acceptance and premium receipt.","The policy can be voided if any information is untrue, incorrect, or incomplete.","The proposer must provide bank details for electronic fund transfer of payments and claims.","The form includes a statutory warning about prohibition of rebates under Insurance Act."],"title":"Group Smart Health - Micro Insurance Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"post or as per intermediary instructions","address":"Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. Maharashtra, India"},"purpose":"proposal","sections":[{"title":"Proposer's Information","fields":[{"help":"Permanent Account Number of proposer","type":"text","label":"PAN*","options":[],"required":true,"pdf_field":""},{"help":"Full legal name of proposer entity","type":"text","label":"Name of the Proposer/ Group Administrator/ Bank/ Financial Institution (Organisation/ Institute/ Association)*","options":[],"required":true,"pdf_field":""},{"help":"Nature of business or activity","type":"text","label":"Proposer’s Trade/ Business/ Activity*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If mailing address differs, fill here","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Proposer's email address","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Contact No.*","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Goods and Services Tax Identification Number","type":"text","label":"GSTIN","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Existing policy number if applicable","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Start date of policy","type":"date","label":"Policy Period: From","options":[],"required":true,"pdf_field":""},{"help":"End date of policy","type":"date","label":"To: Midnight of","options":[],"required":true,"pdf_field":""},{"help":"Duration in years/months/days/hours","type":"text","label":"Policy Tenure","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Category: Individual/ Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Total persons covered","type":"number","label":"Number of Persons to be insured","options":[],"required":true,"pdf_field":""},{"help":"List categories Cat 1 to Cat 5","type":"table","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, etc)","options":[],"required":false,"pdf_field":""},{"help":"Applicable only to credit linked policies","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Frequency of installment payment","type":"choice","label":"If yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Benefit Details","fields":[{"help":"Select benefits to opt for","type":"checkbox","label":"Tick on Cover You want to opt","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"Sum Insured/ Daily Cash Amount","options":[],"required":false,"pdf_field":""},{"help":"Specify deductible or co-pay if any","type":"text","label":"Remarks (Deductible/ Co-pay as applicable)","options":[],"required":false,"pdf_field":""},{"help":"Includes Death, Disablement, Hospitalisation, Daily Cash, OPD, Convalescence benefits","type":"table","label":"Animal, Insect and Reptile Attack Benefit","options":[],"required":false,"pdf_field":""},{"help":"Fixed Benefit, Hospitalisation, Daily Cash, OPD, Convalescence","type":"table","label":"Specific Vector Borne Disease Benefit","options":[],"required":false,"pdf_field":""},{"help":"Fixed Benefit, Hospitalisation, Daily Cash, OPD, Convalescence","type":"table","label":"Specific Communicable Disease Benefit","options":[],"required":false,"pdf_field":""},{"help":"Specific Critical Illness Benefit and Daily Cash Benefit","type":"table","label":"Critical Illness Benefit","options":[],"required":false,"pdf_field":""},{"help":"Due to Accident, Critical Illness, Illness/Injury with EMI amount and number of EMIs","type":"table","label":"Recurring Payout Benefit","options":[],"required":false,"pdf_field":""},{"help":"OPD Expenses, Dental, Vision, AYUSH, Accident Treatment","type":"table","label":"OPD Benefit","options":[],"required":false,"pdf_field":""},{"help":"Day Care Procedure and Surgery Benefit with EMI details","type":"table","label":"Surgery Benefit","options":[],"required":false,"pdf_field":""},{"help":"Amount in INR","type":"amount","label":"Maternity Complication Benefit","options":[],"required":false,"pdf_field":""},{"help":"Compassionate Visit, Repatriation of Mortal Remains, Convalescence Benefit","type":"table","label":"Other Benefits","options":[],"required":false,"pdf_field":""},{"help":"Due to Accident, Critical Illness, Illness/Injury with monthly amount and number of months","type":"table","label":"Loss of Job Benefit","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Applicable for credit linked policies","type":"text","label":"Membership ID/ Employee Number/ Account Number pertaining to Credit (#)","options":[],"required":true,"pdf_field":""},{"help":"Applicable for credit linked policies","type":"text","label":"Name of the Financier (#)","options":[],"required":false,"pdf_field":""},{"help":"Applicable for credit linked policies","type":"text","label":"Credit Tenure (#)","options":[],"required":false,"pdf_field":""},{"help":"Full name of insured person","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Category of insured","type":"text","label":"Category","options":[],"required":true,"pdf_field":""},{"help":"Applicable for credit linked policies","type":"choice","label":"Applicant / Co-applicant (#)","options":["Applicant","Co-applicant"],"required":false,"pdf_field":""},{"help":"Date of birth of insured","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Applicable for credit linked policies","type":"date","label":"Credit sanctioned date (#)","options":[],"required":false,"pdf_field":""},{"help":"Applicable for credit linked policies","type":"amount","label":"Credit Amount / outstanding credit amount (#)","options":[],"required":false,"pdf_field":""},{"help":"Relation to proposer or insured","type":"text","label":"Relationship with the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Job title or occupation","type":"text","label":"Designation/ Occupation","options":[],"required":true,"pdf_field":""},{"help":"Specify any pre-existing illness","type":"text","label":"Any existing illness","options":[],"required":false,"pdf_field":""},{"help":"Specify waiting period in months","type":"number","label":"Pre-existing Disease waiting period – months","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"For past 3 policy periods or less","type":"text","label":"Policy Period From – To","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insurer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy number","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Number of members covered","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of insured person","type":"text","label":"Insured Name*","options":[],"required":true,"pdf_field":""},{"help":"Name of nominee","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"Relation 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":"","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Present Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"For claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Total share must not exceed 100%","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Cheque or Demand Draft number","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Cheque / Demand Draft","options":["Cheque","Demand Draft"],"required":false,"pdf_field":""},{"help":"Select if payment by credit card","type":"checkbox","label":"Credit Card","options":[],"required":false,"pdf_field":""},{"help":"Select if payment online","type":"checkbox","label":"Online Payment","options":[],"required":false,"pdf_field":""},{"help":"Payment amount","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Bank name","type":"text","label":"Drawn On","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"For Credit / Debit Card - Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign or thumb impression","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Sales person signature","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":""},{"help":"Answer if PEP applies","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":true,"pdf_field":""},{"help":"Answer if applicable","type":"yes-no","label":"Are you a Non-Profit Organization?* (only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Group Smart Health - Micro Insurance policies","attachments":["Additional sheets if more space is needed for answers","Cancelled Cheque for bank details","Additional sheet if more than 1 nominee"],"declarations":["The proposer declares all information is true, complete and accurate to the best of their knowledge.","The policy will be issued only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and other information for underwriting and claims.","The company may share proposal and medical information with regulatory authorities.","Policy and service communications will be sent electronically unless physical copy requested.","Consent is given to verify identity/address through government portals for KYC.","Consent is given to share medical records via ABHA number if available.","Premiums are paid from bonafide sources and comply with anti-money laundering laws.","Consent to block premium payment under BIMA ASBA facility upon proposal acceptance."],"dropped_labels":12},"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/5564-group-smart-health-micro-insurance-proposal-form"}