{"id":5573,"title":"Empower 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/Empower_Proposal_Form_ZK_v1_25_26_11082025_7a6297fcfd.pdf","sha256":"611251320d264c9543de180b38b66ea92291a6b28315d5287135d0b6b46b9aea","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Empower insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and payment details for underwriting and policy issuance.","notes":["Fill the form in BLOCK LETTERS.","All 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 is not obliged to issue a policy upon submission of this form or payment.","If proposal is not accepted, payment will be refunded without interest.","The proposer must sign and date the form at required places.","The proposer may request a physical copy of the policy if desired.","The proposer must provide bank details for electronic fund transfer of claims and refunds.","The proposer must provide PAN or Form 60 if PAN is not available."],"title":"Empower 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. Email: care@zurichkotak.com"},"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 full name in first, middle, last name format","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":"Include Address Line 1, Line 2, Nearest 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 is different from permanent address","type":"text","label":"Correspondence Address*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID*","options":[],"required":true,"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":"If applicable","type":"text","label":"GSTIN","options":[],"required":false,"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":false,"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":false,"pdf_field":""},{"help":"Tick applicable proofs","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 Reference Number","type":"text","label":"If 'Yes', CRN","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Zurich Kotak Group Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If 'Yes', Employee ID","options":[],"required":false,"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":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"Name of 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":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"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, provide ABHA number","type":"text","label":"ABHA ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Health History / Details","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":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Diabetes Mellitus - If Yes provide duration, type I or II and name of medication","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"High BP, Cholesterol - If Yes since when and medication being taken","options":[],"required":false,"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":false,"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":"Provide duration if hospitalized","type":"text","label":"Period of hospitalization","options":[],"required":false,"pdf_field":""},{"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":"Provide details if smoking/tobacco consumption is Yes","type":"text","label":"If Yes, Duration and Quantity per day","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Alcohol consumption- Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if alcohol consumption is Yes","type":"text","label":"If Yes, Duration and Quantity","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insurance Company","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Base Sum Insured (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Claim amount paid/rejected","options":["Paid","Rejected"],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Year of claim","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Tick all applicable","type":"checkbox","label":"Have You or any of the person proposed to be insured ever suffered from / are suffering from any of the following (tick 'YES' if applicable): 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":["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"],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If any accident in past please give details: Year of Accident, Accident resulting in to deformity or disability hampering mobility","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Nominee Mobile Number","options":[],"required":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":"","type":"text","label":"Nominee Bank Name and Account Details","options":[],"required":false,"pdf_field":""},{"help":"Total share for all nominees cannot exceed 100%","type":"number","label":"% of claim share*","options":[],"required":true,"pdf_field":""},{"help":"Provide if nominee is minor","type":"text","label":"Where Nominee is a minor, give details of Appointee: Name of the Appointee, Date of Birth DD/MM/YYYY, Relationship with the Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposal Details","fields":[{"help":"Select sum insured amount","type":"choice","label":"Sum Insured (in INR)","options":["3 lac","4 lac","5 lac","7.5 lac","10 lac"],"required":true,"pdf_field":""},{"help":"Select deductible amount","type":"choice","label":"Deductible","options":["50 k","1 lac","2 lac"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Proposed Start Date*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"If payment by cheque or demand draft","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Premium amount","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Date of cheque/DD","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"If payment by card","type":"text","label":"For Credit/Debit Card: Transaction Reference No.","options":[],"required":false,"pdf_field":""},{"help":"Date of card transaction","type":"date","label":"Transaction Date","options":[],"required":false,"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":false,"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":"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":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature and Stamp of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Declarations","fields":[{"help":"PEP means individuals with prominent public functions","type":"yes-no","label":"Are You or any of the proposed applicants or close relatives is/are associated to Politically Exposed Person (PEP)? *","options":["Yes","No"],"required":true,"pdf_field":""},{"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":"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":""}],"filled_by":"proposer / intermediary / authorized representative / agent"}],"deadlines":[],"applies_to":"Empower insurance policy proposal","attachments":["Proof of Identity (POI) and Proof of Address (POA) documents as applicable","Documents for any existing illness or continuous medication","Documents for any past hospitalization","Cancelled Cheque (if applicable)","Insurance Repository Application form (if EIA account creation requested)"],"declarations":["The proposer declares that all information provided is true, complete and accurate to the best of their knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify the company of any change in occupation or health after submission but before 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 insurer, TPA, 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 portals for KYC.","Consent is given to share medical records via ABHA number if available.","The proposer declares if they qualify as a High Net Worth Individual (HNI) with net worth of ₹50 crore or more.","All premiums are paid from bona fide sources and not from proceeds of crime as per AML declaration.","The insurance company may cancel the contract if found guilty under money laundering laws.","The proposer confirms understanding of policy features and terms as explained by the agent/intermediary.","The proposer declares if associated with Politically Exposed Persons or is a Non-Profit Organization (entity only)."],"dropped_labels":10},"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/5573-empower-proposal-form"}