{"id":5568,"title":"LiveWise 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/Live_Wise_Proposal_Form_ZK_v1_25_26_11082025_ce66d39f54.pdf","sha256":"9681a90391dc8e09deb64647c4686544c79c1b55c124307f41c380b49bbcded6","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the LiveWise insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and coverage details for underwriting.","notes":["Fill the form in BLOCK LETTERS.","Fields marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","Online or credit card premium payment must be made by the policyholder; third party payments are not allowed.","Use original documents for proofs and medical records.","The company’s acceptance of the proposal is at its sole discretion.","Electronic fund transfer is mandatory for payments and refunds as per regulatory requirements.","The proposer must sign and date the form at the designated places."],"title":"LiveWise Proposal Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","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":"","type":"choice","label":"Title Mr. / Miss / Mrs. / M/s / Others","options":["Mr.","Miss","Mrs.","M/s","Others"],"required":null,"pdf_field":""},{"help":"Enter first, middle, and last name in block letters","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"Fill address lines, landmark, city/district, state, pin code, country","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is Correspondence Address same as Permanent Address? *","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill only if correspondence address differs from permanent address","type":"text","label":"Correspondence Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Occupation*","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Profession*","options":["CA","Paramilitary Services","Govt. Teacher","Govt. Employee","Medical Doctor","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Annual Income","options":["Up to 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 if no PAN","type":"text","label":"PAN*","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Form 60 (only in case the customer does not have PAN No.)","options":[],"required":null,"pdf_field":""},{"help":"Tick applicable proofs and specify if Others","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [(    ) Tick whichever is applicable]","options":["PAN","Ration Card","Passport","Driving License","Voter ID Card","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you an existing customer of Kotak Mahindra Bank Ltd. / Kotak Mahindra Prime Ltd.?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Customer Relationship Number","type":"text","label":"If 'Yes', CRN","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Kotak Group Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If 'Yes', Employee ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If 'Yes', Policy No","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Cashless tests for each insured person","type":"yes-no","label":"Annual Health Check Up","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"100% of Base Sum Insured as double cover","type":"yes-no","label":"Double Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"100% increase in Base Sum Insured for each claim free year up to 5 times","type":"yes-no","label":"Cumulative Bonus Booster","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indemnity cover for non-medical items as per Annexure II List 1","type":"yes-no","label":"Consumables Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select pack 1 to 7 if Yes","type":"choice","label":"Value Added Services (As per Annexure A)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Up to INR 5 Lacs per year","type":"yes-no","label":"Air Ambulance Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Reduce waiting period from 36 months","type":"yes-no","label":"Pre-existing Diseases Waiting Period","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select reduced waiting period","type":"choice","label":"If Yes, Select from below options","options":["24 months","12 months"],"required":null,"pdf_field":""},{"help":"Cover at listed hospitals up to sum insured; other hospitals with 20% co-payment","type":"yes-no","label":"Smart Select","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"If Yes, Select from below options","options":["Single Private Room Cover","Shared Room Cover"],"required":null,"pdf_field":""},{"help":"Deductible applicable per policy year on aggregate claims","type":"yes-no","label":"Deductible","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select deductible amount","type":"choice","label":"If Yes, Select from below options","options":["25000","50000","100000","200000","500000","1000000"],"required":null,"pdf_field":""},{"help":"Select co-payment percentage if Yes","type":"yes-no","label":"Voluntary Co-payment","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"If Yes, Select from below options","options":["10%","15%","20%","25%","30%","35%","40%","45%","50%"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposal Details","fields":[{"help":"","type":"choice","label":"Type of Cover*","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"5 lac not available for Zone I","type":"choice","label":"Sum Insured","options":["5 lac","7.5 lac","10 lac","15 lac","25 lac","50 lac","100 lac"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period*","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""},{"help":"Zone I and Zone II areas defined in form","type":"choice","label":"Please select the Zone:","options":["Zone I","Zone II"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Installment Option*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"If yes, Installment Frequency*","options":["Monthly","Quarterly","Half yearly"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"For each insured person","type":"text","label":"Name in Full*","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status*","options":["Single","Married","Others"],"required":true,"pdf_field":""},{"help":"If available","type":"text","label":"ABHA ID","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"","type":"text","label":"Nominee Name*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship of Nominee with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"If nominee is minor","type":"text","label":"Name of the Appointee","options":[],"required":null,"pdf_field":""},{"help":"Appointee's DOB","type":"date","label":"Date of Birth DD/MM/YYYY","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Hospitalisation Information","fields":[{"help":"","type":"yes-no","label":"Are you currently in good mental and physical health – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide documents","type":"yes-no","label":"Are you currently suffering or previously suffered from any illness and on continuous medication for same - Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name the medication and duration since on treatment","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Diabetes Mellitus - If Yes provide duration, type I or II and name of medication","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"High BP, Cholesterol - If Yes since when and medication being taken","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Have you undergone any medical test or health check–up in the past 6 month if yes then please mention if any abnormal result detected","options":[],"required":null,"pdf_field":""},{"help":"If Yes, provide documents","type":"yes-no","label":"Any hospitalization in the past – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of hospitalization","options":[],"required":null,"pdf_field":""},{"help":"Mark Yes/No for each condition per insured","type":"table","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following (tick 'YES' for insured wherever applicable): Infections / Allergies, HIV / AIDs, Cancer / Tumor / Cyst, Nutritional / Endocrinal disorders / Diabetes, Mental psychiatric Disorders, Nervous system Disorders, Disorders of the Eyes / Ears / Nose / throat, Disorders of the circulatory system / Heart Disease/ hypertension, Respiratory Infections and Diseases, Asthma, Bones and Joints, Spondylitis / arthritis etc., Diseases of Stomach, Intestines, liver, appendix, Kidney and urinary system, Pregnant / Gynaecological Disorders / any disorder of Prostrate, Birth Defects, Accidents / burns","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If any accident in past please give details: Year of Accident","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Accident resulting in to deformity or disability hampering mobility","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Lifestyle Information","fields":[{"help":"","type":"yes-no","label":"Have You or any of the person proposed has any of the following Habit? Smoking / Tobacco consumption – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, Duration and Quantity per day","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Alcohol consumption- Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, Duration and Quantity","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Health Insurance Details","fields":[{"help":"","type":"text","label":"Type of Policy","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Base Sum Insured (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Claims","fields":[{"help":"","type":"text","label":"Ailment for which claim was made","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim amount paid/rejected","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Year of claim","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Others","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide full details","type":"yes-no","label":"Have You or any person proposed to be insured under the Policy has ever been refused insurance cover by an insurance company or been accepted on special terms? (YES / No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if any","type":"text","label":"Any Pre-existing diseases","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Drawn On","options":[],"required":null,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"For Credit/Debit Card - Transaction Reference No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details","fields":[{"help":"Select if applicable","type":"checkbox","label":"Bank details as per premium cheque to be used for electronic fund transfer","options":[],"required":null,"pdf_field":""},{"help":"Select if applicable","type":"checkbox","label":"No existing Bank Account","options":[],"required":null,"pdf_field":""},{"help":"Select if applicable","type":"checkbox","label":"I agree to open a bank account and provide my bank account details to the Company for electronic fund transfer as mode of payment","options":[],"required":null,"pdf_field":""},{"help":"Select if applicable","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","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":""}],"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":"If Yes, fill Insurance Repository Application form","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Mandatory for EIA account","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Intermediary/ Sales Person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"LiveWise insurance policy proposal","attachments":["Proof of Identity (POI) and Proof of Address (POA) documents as applicable","Documents for any ongoing medication if applicable","Documents for any past hospitalization if applicable","Cancelled Cheque for bank details if applicable","Insurance Repository Application form if EIA account creation requested"],"declarations":["The information provided is true, complete, and forms the basis of the insurance policy.","The policy will be effective only after full payment of premium.","Any change in occupation or health after proposal submission must be notified before risk acceptance.","Consent is given to the company to seek medical and insurance information for underwriting and claims.","Consent is given to share proposal and medical records with government and regulatory authorities.","Policy and service communications will be sent electronically unless physical copy is requested.","Consent is given to verify identity/address through government registries for KYC.","Consent is given to share medical records via ABHA number if available.","Proposer may be classified as High Net Worth Individual if declared.","All premiums are paid from bona fide sources and comply with anti-money laundering laws.","The company may cancel the contract if premiums are linked to proceeds of crime.","Declarations regarding association with Politically Exposed Persons and Non-Profit Organization status must be made.","No rebates or inducements are allowed under Section 41 of Insurance Act 1938."],"dropped_labels":8},"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/5568-livewise-proposal-form"}