{"id":5574,"title":"Health 360 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/Health_360_Proposal_Form_ZK_v1_25_26_11082025_5deef935a6.pdf","sha256":"8a1e7dfc693c3b4228485bf47cacdfae40842aa05f8c98f553578d010263bcf6","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families to apply for the Health 360 insurance policy from Zurich Kotak General Insurance Company. The proposer fills it to provide personal, health, and nominee details for insurance coverage.","notes":["Fill the proposal form in BLOCK LETTERS.","All fields marked with * are mandatory.","Issuance of the form does not mean acceptance of the proposal.","Provide all information fully, accurately, and correctly.","Attach additional sheets if space is insufficient, indicating question numbers.","Use original documents for proofs and claims.","Family floater policy covers maximum 2 adults and 3 dependent children.","Total nominee claim share cannot exceed 100%.","Global Cover is not applicable for insured persons above 65 years or NRI customers.","Global Cover Sum Insured is restricted up to Base Sum Insured subject to max INR 2 Cr.","Point of Sale (PoS) is applicable for Sum Insured of 5 Lakhs.","Electronic fund transfer is mandatory for payments and refunds as per regulatory requirements.","The company is not liable if NEFT transactions fail.","Prohibition of rebates under Section 41 of Insurance Act applies."],"title":"Health 360 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 full name: First Name, Middle Name, Last Name","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":"If different from permanent address, provide full 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":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":"","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":"Provide PAN 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","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":"If Yes, provide Employee ID","type":"yes-no","label":"Zurich/Kotak Group Company Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide Employee ID and Corporate Email ID","type":"yes-no","label":"Are you a salaried person?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide CRN","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":"If Yes, provide Policy No","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"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":"","type":"choice","label":"Plan Name","options":["Silver","Gold","Platinum","Diamond"],"required":null,"pdf_field":""},{"help":"Select sum insured based on plan","type":"choice","label":"Base Sum Insured*","options":["Silver: 5 lac, 7.5 lac, 10 lac","Gold: 10 lac, 15 lac, 20 lac, 25 lac","Platinum: 50 lac, 100 lac, 200 lac, 500 lac","Diamond: Unlimited Sum Insured"],"required":true,"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: Delhi NCR, Nasik, Gujarat; Zone II: Kolkata, Mumbai, Palghar, Raigarh (MH), Thane, Chennai, Jaipur, Rest of Haryana; Zone III: Rest of India excluding Zone I & II","type":"choice","label":"Please select the Zone:","options":["Zone I","Zone II","Zone III"],"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":""},{"help":"Select Yes or No for each optional cover listed by plan (Silver, Gold, Platinum, Diamond). Covers include Global Cover, Cumulative Bonus Booster, Double Cover, Cash Bag, Step Up Benefit, One Plus Benefit, Convalescence Benefit, Home Nursing Benefit, Hospital Daily Cash, Daily Cash for Accompanying an Insured Child, Compassionate Visit, Essential Equipment Cover, Maternity Benefit (with sub-options), Critical Illness Cover, Personal Accident Cover, Pre-existing disease Waiting Period Modification, Specified disease/procedure Waiting Period Modification, Smart Select, Cap on Room Rent, Room Category Modification, Deductible, Voluntary Co-pay.","type":"table","label":"Optional Covers","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Information","fields":[{"help":"","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":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 not created, visit https://healthid.ndhm.gov.in/ to create","type":"text","label":"ABHA Number","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 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 months? If yes, 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":"","type":"text","label":"If any accident in past please give details: Year of Accident","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Lifestyle Information","fields":[{"help":"If Yes, provide duration and quantity per day","type":"yes-no","label":"Smoking / Tobacco consumption – Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide duration and quantity","type":"yes-no","label":"Alcohol consumption- Yes / No","options":["Yes","No"],"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":"Provide details if any","type":"text","label":"Any Pre-existing diseases","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Acknowledgement and Bank Account Details","fields":[{"help":"Name of proposer","type":"text","label":"Received from Ms./Mrs./ Mr.","options":[],"required":null,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"a sum of Rs.","options":[],"required":null,"pdf_field":""},{"help":"Payment mode","type":"text","label":"Through Cheque/DD","options":[],"required":null,"pdf_field":""},{"help":"Bank account for payments/refunds","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":""},{"help":"","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":"","type":"checkbox","label":"Cancelled Cheque submitted of Other Bank","options":[],"required":null,"pdf_field":""},{"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":"","type":"email","label":"Email id (to be registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration for Agent","fields":[{"help":"","type":"signature","label":"Signature/Thumb impression of Proposer","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":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Health 360 individual and family floater health insurance policies","attachments":["Proof of Identity (POI) and Proof of Address (POA)","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)","Additional sheets if space is insufficient for answers"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The company may seek medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","The company may share proposal and medical information with government and regulatory authorities.","Policy and service communications will be sent by email unless physical copy is requested.","Consent is given to verify identity/address through official registries for KYC purposes.","Consent is given to share medical records with insurer/TPA via ABHA number if available.","Proposer may declare as High Net Worth Individual if applicable.","All premiums are paid from bona fide sources and not from proceeds of crime as per AML regulations.","Agent declares having explained policy features and terms to the proposer."],"dropped_labels":17},"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/5574-health-360-proposal-form"}