{"id":5594,"title":"Environmental Impairment Liability Insurance Policy 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/Proposal_Form_EIL_befb97c87d.pdf","sha256":"d08be9e86430c95be3f3f4338e71cf6ec0b1f9ff925bd924a7481ca3dccc9ee0","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by companies or organizations applying for Environmental Impairment Liability Insurance. The proposer (applicant company) fills it to provide detailed information about their business, site, environmental risks, and compliance.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","Attach additional sheets if space is insufficient, indicating question number.","Information provided will be treated in strict confidence.","Original bills or documents may be required for claims (implied).","Use the email id registered with Insurance Repository for EIA details.","The insurer is not liable if NEFT transaction does not complete.","The proposal form and payment do not oblige the insurer to issue a policy."],"title":"Environmental Impairment Liability Insurance Policy Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Business Details","fields":[{"help":"","type":"text","label":"Company Website / URL","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is the Communication address same as the Head Office address ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill only if communication address differs from head office","type":"text","label":"Communication Address","options":[],"required":null,"pdf_field":""},{"help":"Start date of policy period","type":"date","label":"From:","options":[],"required":null,"pdf_field":""},{"help":"End date of policy period","type":"date","label":"To:","options":[],"required":null,"pdf_field":""},{"help":"Name of the company or organization applying","type":"text","label":"1. Name of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Full address of the head office","type":"text","label":"2. Address of Head Office","options":[],"required":true,"pdf_field":""},{"help":"Specify policy start and end dates","type":"text","label":"3. Policy Period","options":[],"required":true,"pdf_field":""},{"help":"Country where the company is registered","type":"text","label":"4. Country of Registration","options":[],"required":true,"pdf_field":""},{"help":"Date when the company was incorporated or formed","type":"date","label":"5. Date of incorporation/formation","options":[],"required":true,"pdf_field":""},{"help":"Describe the business activities","type":"text","label":"6. Nature of the business of the Applicant","options":[],"required":true,"pdf_field":""},{"help":"Describe previous uses of the site","type":"text","label":"7. Site History: Description of past occupancies and land use","options":[],"required":true,"pdf_field":""},{"help":"Describe environment around the site","type":"text","label":"8. Surrounding Environmental & Land Use: Describe the surrounding environment/land use and proximity to all industrial complexes, warehouses, parking lot, schools, residential properties, public buildings, farmland, vacant land, landfills, drum storage area, sensitive habitats, waterways, drinking wells, etc.","options":[],"required":true,"pdf_field":""},{"help":"Duration of occupancy at the site","type":"text","label":"9. How long has your company occupied this site?","options":[],"required":true,"pdf_field":""},{"help":"Include size of property, number and type of buildings, waste water facilities, manufacturing operations, land surface, underground piping, support facilities, underground storage tanks","type":"text","label":"10. Describe the existing operational facilities","options":[],"required":true,"pdf_field":""},{"help":"Number of storage areas, quantities stored, type of secondary containment","type":"text","label":"11. Description of the container / drum storage areas","options":[],"required":true,"pdf_field":""},{"help":"Number, capacity, contents, construction, age, secondary containment, inspection details","type":"text","label":"12. Description of the aboveground storage tank areas","options":[],"required":true,"pdf_field":""},{"help":"Attach copies if yes","type":"yes-no","label":"13. Have any environmental surveys, audits or investigation been conducted at the site within the past five years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide documentation if yes","type":"yes-no","label":"14. Have there been any previous pollution events on the Site (i.e spills, releases, fires, explosions)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide documentation if yes","type":"yes-no","label":"15. Is there any existing soil or groundwater contamination on-site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe projects, documents, agencies, schedule, costs if yes","type":"yes-no","label":"16. Are there any ongoing/planned soil or groundwater remediation projects at the site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide documentation if yes","type":"yes-no","label":"17. Are there any environmental lawsuits pending against the site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details on number, sampling frequency, who conducts, problems noted, groundwater flow direction","type":"yes-no","label":"18. Are there any on-site groundwater monitoring wells?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Include quantities, storage methods, environmental controls, annual usage","type":"text","label":"19. Describe the types of raw materials (solids and liquids) stored on-site","options":[],"required":true,"pdf_field":""},{"help":"If yes, provide type, materials, years stored, permits, amount, hazard class, storage method, construction, age, maintenance","type":"yes-no","label":"20. Is any waste currently disposed on-site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, describe wastewater types, treatment process, discharge location, permit compliance","type":"yes-no","label":"21. Does the facility have a Wastewater Permit?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, describe air monitoring/control systems and any air problems","type":"yes-no","label":"22. Does the company have an Air Permit at this site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, describe other permits","type":"yes-no","label":"23. Does the facility have any other environmental permits?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide documentation describing equipment and reasons","type":"yes-no","label":"24. Are there any requirements or plans to install or upgrade air pollution control devices or wastewater treatment equipment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide fines levied and corrective steps taken","type":"yes-no","label":"25. Has the facility received any notices of violation?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide fines levied and corrective steps taken","type":"yes-no","label":"26. Has the facility received any Consent Orders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide fines levied and corrective steps taken","type":"yes-no","label":"27. Has the facility received any other environmental violations?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach copies of plans if yes; describe experience and training of emergency team","type":"checkbox","label":"28. Does the company have any of the following Plans?","options":["Emergency Response Plan in place","Spill Control Plan in place","Fire Protection Program in place","On-site Emergency Response Team"],"required":null,"pdf_field":""},{"help":"If yes, provide details on locations","type":"yes-no","label":"29. Is the company planning on divesting any location during the upcoming policy period?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide information on planned projects","type":"yes-no","label":"30. Does the company anticipate redevelopment or development projects at any sites during the upcoming policy period?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide type of disposal facility, name and address, material description, quantity, and waste permit status","type":"yes-no","label":"31. Has waste historically been transported & disposed of off-site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide carrier names and addresses, material type and amount, trips per year, distance, loading/unloading procedures, transporter selection and insurance details","type":"yes-no","label":"32. Are 3rd Party Carriers used to transport waste or products off-site?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide names and addresses, material types and amounts, packaging, facility descriptions, dedicated areas, environmental liabilities, insurance coverage","type":"yes-no","label":"33. Are non-owned locations used to store products?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide product descriptions, quantities, shipping methods, containers, loading/unloading, trips per year, distance, driver training and selection procedures","type":"choice","label":"34. Do you (insured) transport Products off-site with owned vehicles?","options":["Yes","No","N/A"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Underground Storage Tanks","fields":[{"help":"Number, capacity, contents, construction, age, leak detection, inspections, tank management program, regulatory compliance","type":"text","label":"35. Description of the underground storage tank areas","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select source of funds for premium payment","type":"choice","label":"Sources of funds","options":["Salary","Business","Investments","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Company’s CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Goods and Services Tax Identification Number","type":"text","label":"GSTIN","options":[],"required":null,"pdf_field":""},{"help":"Name of authorized signatory","type":"text","label":"Authorised Signatory Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details and Payment Details","fields":[{"help":"Cheque or Demand Draft number if payment by these methods","type":"text","label":"Cheque / D.D #","options":[],"required":null,"pdf_field":""},{"help":"Name of payee on cheque or DD","type":"text","label":"Drawn To","options":[],"required":null,"pdf_field":""},{"help":"Bank and branch of cheque/DD","type":"text","label":"Bank and Branch Name","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":"Bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":null,"pdf_field":""},{"help":"Amount on cheque/DD or transaction","type":"amount","label":"Drawn Amount","options":[],"required":null,"pdf_field":""},{"help":"Date of payment transaction","type":"date","label":"Transaction Date","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for electronic fund transfer","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Bank name for electronic fund transfer","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Name of account holder for electronic fund transfer","type":"text","label":"Account Holder name","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Indicate if you have an Electronic Insurance Account","type":"choice","label":"Do you have an EIA Account","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you want the insurer to create an EIA account","type":"choice","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Email registered with Insurance Repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""},{"help":"Address as per EIA account","type":"text","label":"Your address details as mentioned in the EIA account shall override the address provided in this application for Insurance.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign or thumb impression of proposer","type":"signature","label":"Signature / Thumb impression of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary / Sales person*","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place*","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date*","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized representative if proposer is person with disability","type":"signature","label":"Signature of Authorised Representative*","options":[],"required":true,"pdf_field":""},{"help":"Authorization of representative to assist in form completion","type":"text","label":"Declaration in case the proposer/policyholder is person with disability (PWD)","options":[],"required":null,"pdf_field":""},{"help":"Agent declares having explained policy features and terms to proposer","type":"signature","label":"Declaration for Agent","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"},{"title":"Additional Declarations","fields":[{"help":"Declare if associated with PEP","type":"choice","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":"Declare if non-profit organization","type":"choice","label":"Are you a Non-Profit Organization?*(only in case of an entity)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select type of organization","type":"choice","label":"In case of entity, Type of Organisation making the payment","options":["Limited Company","International Organisation","Section 25 Company","Non-Government Organisation (NGO)","Government Organisation","Co-operatives","Trust","Partnership","Society","Others"],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Environmental Impairment Liability Insurance policies","attachments":["Additional sheets if more space is needed for answers","Copy of last tank/vessel inspection report","Copies of environmental surveys, audits or investigations conducted in past five years","Documentation of previous pollution events","Documentation of soil or groundwater contamination","Documentation of ongoing/planned remediation projects","Documentation of pending environmental lawsuits","Copies of Emergency Response Plan and Spill Control Plan if available","Copy of last underground storage tank inspection","Insurance Repository Application form if EIA account exists"],"declarations":["Statements made in the proposal form are true, complete and form the basis of the policy.","The insurer's liability starts only after acceptance of the proposal and receipt of premium.","The policy is voidable if any material information is untrue, incorrect, or withheld.","Consent to verify identity/address through official registries for KYC purposes.","All premiums are paid from bonafide sources and not from proceeds of crime.","No rebates are allowed as inducement to take or renew insurance as per Insurance Act.","Agent declares having explained policy features and terms to the proposer.","Proposer consents to receive policy and service communication in soft copy unless physical copy requested."],"dropped_labels":3},"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/5594-environmental-impairment-liability-insurance-policy-proposal-form"}