{"id":5565,"title":"Group Health Assure - 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_Health_Assure_Micro_Insurance_Proposal_Form_ZK_v1_25_26_11082025_a3eeb83ec9.pdf","sha256":"99abd646d9a996a35cca5f84c148d6ee96d85c950395a9c10f5d0bd644c51a32","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (individual or group administrator) to apply for the Group Health Assure - Micro Insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, coverage, and payment details for insurance underwriting.","notes":["Fill the form in BLOCK LETTERS","Fields marked with * are mandatory","Attach additional sheets if more space is needed, indicating question number","Use original documents for verification","Provide cancelled cheque for bank details","Submission of proposal or payment does not guarantee policy issuance","Policy issuance is subject to underwriting and receipt of premium in full and on time"],"title":"Group Health Assure - Micro Insurance 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":"Proposer’s Information","fields":[{"help":"Enter the quote number if available","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Code","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of the quote","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Sales Manager Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Service RM","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Branch code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary business vertical","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Client Ref. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"SP Name/Code","options":[],"required":null,"pdf_field":""},{"help":"Central KYC Registry number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number of the proposer","type":"text","label":"PAN*:","options":[],"required":true,"pdf_field":""},{"help":"Name of the Authorised Signatory","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Designation of the Authorised Signatory","type":"text","label":"Designation:","options":[],"required":null,"pdf_field":""},{"help":"CKYC number of the Authorised Signatory if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI):","options":[],"required":null,"pdf_field":""},{"help":"Full name of the 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 of the proposer","type":"text","label":"Proposer’s Trade/ Business/ Activity*","options":[],"required":true,"pdf_field":""},{"help":"Registered office address line 1","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Registered office address line 2","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Nearest landmark to the registered office","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"City or district of registered office","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"State of registered office","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Full registered office address","type":"text","label":"Proposer’s Registered Office Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of registered office","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Postal code of registered office","type":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is the Mailing Address same as the Registered Office Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Mailing address line 1 if different","type":"text","label":"Address (Line 1)","options":[],"required":null,"pdf_field":""},{"help":"Mailing address line 2 if different","type":"text","label":"Address (Line 2)","options":[],"required":null,"pdf_field":""},{"help":"Nearest landmark to mailing address","type":"text","label":"Nearest Landmark","options":[],"required":null,"pdf_field":""},{"help":"City or district of mailing address","type":"text","label":"City / District","options":[],"required":null,"pdf_field":""},{"help":"State of mailing address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Full mailing address","type":"text","label":"Proposer’s Mailing Address*","options":[],"required":true,"pdf_field":""},{"help":"Country of mailing address","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Postal code of mailing address","type":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Email address of proposer","type":"email","label":"Email ID*","options":[],"required":true,"pdf_field":""},{"help":"Contact phone 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 if applicable","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you have an existing policy with the company","type":"choice","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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Start date of policy period","type":"date","label":"Policy Period: From","options":[],"required":true,"pdf_field":""},{"help":"Select policy category","type":"choice","label":"Policy Category: Individual/ Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Enter total number of persons to be insured","type":"number","label":"Number of Persons to be insured","options":[],"required":true,"pdf_field":""},{"help":"Select one TPA","type":"choice","label":"Please select your choice of TPA (Third Party Administrator) to service your cashless claims","options":["Family Health Plan Insurance TPA Ltd.","Paramount Health Services & Insurance TPA Pvt. Ltd.","Medi Assist Insurance TPA Pvt. Ltd."],"required":true,"pdf_field":""},{"help":"Describe categories Cat 1 to Cat 5","type":"text","label":"Categories of proposed Insured (Add more categories if needed) – (senior management, middle management, management trainee, etc.)","options":[],"required":null,"pdf_field":""},{"help":"List relationships covered under the policy","type":"text","label":"Relationships Covered","options":[],"required":null,"pdf_field":""},{"help":"Specify type of credit if applicable","type":"text","label":"Type of Credit","options":[],"required":null,"pdf_field":""},{"help":"Select if installment payment option is chosen","type":"choice","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select installment frequency if applicable","type":"choice","label":"If yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Waiting Periods and Additional Benefits","fields":[{"help":"Specify waiting period in months","type":"number","label":"Pre-existing Disease waiting period – months","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Wellness Program","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Floater Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Corporate Buffer","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Deductible","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Co-payment","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Disease-wise sublimit","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Policy Details","fields":[{"help":"Enter policy period for past policies","type":"text","label":"Policy Period From - To","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer for past policies","type":"text","label":"Name of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Policy number of past policies","type":"text","label":"Policy number","options":[],"required":null,"pdf_field":""},{"help":"Number of members covered under past policies","type":"number","label":"Number of members covered","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Details","fields":[{"help":"Enter membership or employee number","type":"text","label":"Membership ID/ Employee Number/ Account Number pertaining to Credit","options":[],"required":true,"pdf_field":""},{"help":"Name of financier if credit linked","type":"text","label":"Name of the Financier","options":[],"required":null,"pdf_field":""},{"help":"Credit tenure if applicable","type":"text","label":"Credit Tenure","options":[],"required":null,"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 person","type":"text","label":"Category","options":[],"required":null,"pdf_field":""},{"help":"Select applicant or co-applicant","type":"choice","label":"Applicant / Co-applicant","options":["Applicant","Co-applicant"],"required":null,"pdf_field":""},{"help":"Date of birth of insured person","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Date credit was sanctioned if applicable","type":"date","label":"Credit sanctioned date","options":[],"required":null,"pdf_field":""},{"help":"Credit amount or outstanding amount if applicable","type":"amount","label":"Credit Amount / outstanding credit amount","options":[],"required":null,"pdf_field":""},{"help":"Relationship to proposer or insured","type":"text","label":"Relationship with the Insured Person","options":[],"required":null,"pdf_field":""},{"help":"Occupation or designation of insured person","type":"text","label":"Designation/ Occupation","options":[],"required":null,"pdf_field":""},{"help":"Declare any existing illness","type":"text","label":"Any existing illness","options":[],"required":null,"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":"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":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 of nominee for claim payment","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":null,"pdf_field":""},{"help":"Percentage share of claim for nominee","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Name of appointee if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee - Name of the Appointee","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of appointee","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"Relationship of appointee to nominee","type":"text","label":"Relationship with the Nominee","options":[],"required":null,"pdf_field":""},{"help":"Name of nominee for appointee details","type":"text","label":"Name of the Nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Transaction reference number for card payments","type":"text","label":"For Credit/Debit Card Transaction Reference No.","options":[],"required":null,"pdf_field":""},{"help":"Date of card transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign to declare all information is true and consent given","type":"signature","label":"Signature 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"},{"title":"Bank Account Details for Electronic Fund Transfer","fields":[{"help":"Bank account number for EFT","type":"text","label":"Account No","options":[],"required":null,"pdf_field":""},{"help":"Name of bank","type":"text","label":"Bank Name","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 account holder","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Declaration","fields":[{"help":"Agent signs to confirm explanation of policy terms","type":"signature","label":"Signature & Stamp as applicable of the Insurance Advisor/Specified person of Corporate Agent/Authorised Employee of Broker/Sales person*","options":[],"required":true,"pdf_field":""},{"help":"Proposer signs after understanding policy","type":"signature","label":"Signature / Stamp of the 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":"agent"},{"title":"Declaration for Person with Disability (PWD)","fields":[{"help":"Signature or thumb impression of proposer with disability","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 or authorized representative"},{"title":"Vernacular Declaration","fields":[{"help":"Agent signs to confirm explanation in local language","type":"signature","label":"Signature of Intermediary/Sales Person*","options":[],"required":true,"pdf_field":""},{"help":"Proposer signs after understanding in vernacular","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":"agent and proposer"},{"title":"Additional Declarations","fields":[{"help":"Select Yes or No","type":"choice","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":"Select Yes or No","type":"choice","label":"Are you a Non-Profit Organization?* (only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Signature or thumb impression","type":"signature","label":"Signature / Thumb impression of the 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":["If proposal is not accepted, refund will be made within 15 days from receipt of proposal"],"applies_to":"Group Health Assure - Micro Insurance","attachments":["Additional sheets if more space is required to answer any question","Cancelled Cheque for bank account details"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge","The policy will come into force only after full payment of premium","The proposer will notify any change in occupation or health before risk acceptance","The proposer consents to the company seeking medical and insurance information for underwriting and claims","The proposer authorizes sharing of proposal and medical records with regulatory authorities","Policy and service communications will be sent by email unless physical copy is requested","The proposer consents to KYC verification through government portals","All premiums are paid from bonafide sources and not from proceeds of crime","The company may cancel the contract if money laundering laws are violated","Agent declares having explained policy features and terms to the proposer","Proposer with disability may authorize a representative to assist in completing the form","Agent declares having explained the proposal form in the language understood by the proposer"],"dropped_labels":15},"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/5565-group-health-assure-micro-insurance-proposal-form"}