{"id":5610,"title":"CYBER SECURE+ 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/Cyber_Secure_Proposal_Form_Individual_7ccce54e3e.pdf","sha256":"eaa18440942f875bf86e7651d66296985afe9a56b7eac31d9b5b4820dbd7610a","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals to apply for the Cyber Secure+ insurance policy offered by Zurich Kotak General Insurance Company. The proposer/applicant fills this form to provide personal, contact, and coverage details for the insurance proposal.","notes":["Fill the proposal form in BLOCK LETTERS.","All fields marked with * are mandatory.","Attach additional sheets if space is insufficient and indicate question number.","Policy covers individuals residing in India only.","Family cover is limited to spouse and maximum two children below 18 years.","Total nominee share percentage cannot exceed 100%.","Electronic Insurance Account email id is mandatory if provided.","Submission of proposal or payment does not oblige the company to issue a policy.","If proposal is not accepted, payment will be refunded without interest."],"title":"CYBER SECURE+ PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Applicant Details","fields":[{"help":"Enter the quote number provided","type":"text","label":"Quote No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter the quote date","type":"date","label":"Quote Date*","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Code","options":[],"required":null,"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":"Select appropriate title","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":"Select gender","type":"choice","label":"Gender*","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Policy covers individuals residing in India only","type":"choice","label":"Nationality ##","options":["Indian","Non -Indian","NRI"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Others"],"required":null,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id:","options":[],"required":null,"pdf_field":""},{"help":"Enter full permanent address including Address Line 1, Line 2, Landmark, City/District, State, Pin Code, Country","type":"text","label":"Permanent Address *","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Postal Address same as the Permanent Address?*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide PAN number or tick if Form 60 is submitted","type":"text","label":"PAN* / Form 60 (only in case the customer does not have PAN No.)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide GSTIN if applicable","type":"text","label":"GSTIN:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Nationality*","options":["Indian","Non-Indian","NRI"],"required":true,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Business","Salaried","Professionals","Student","Housewife","Retired","Others"],"required":null,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Additional Proposer Details","fields":[{"help":"Select annual income range","type":"choice","label":"Annual Income","options":["Upto 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":"Enter CKYC number if available","type":"text","label":"CKYC Identifier / Number (Generated by CERSAI)","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable identity and address proofs","type":"checkbox","label":"Proof of Identity (POI) and Proof of Address (POA) [Tick (✓) whichever is applicable]","options":["PAN","Aadhaar","Passport","Driving License","Voter ID","Others (specify)"],"required":null,"pdf_field":""},{"help":"Select Yes or No","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":"Enter Customer Relationship Number if existing customer","type":"text","label":"If ‘Yes’, CRN","options":[],"required":false,"pdf_field":""},{"help":"Select if you are an employee","type":"yes-no","label":"Zurich/ Kotak Group Employees","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter employee ID if applicable","type":"text","label":"If ‘Yes’, Employee ID","options":[],"required":false,"pdf_field":""},{"help":"Select if you have existing policy","type":"yes-no","label":"Any existing policy from Us","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter existing policy number","type":"text","label":"If ‘Yes’, Policy No","options":[],"required":false,"pdf_field":""},{"help":"Select cover type; Family Cover limited to spouse and max two children under 18","type":"choice","label":"Please tick the type of Cover You want to opt for?","options":["Individual Cover","Family Cover"],"required":null,"pdf_field":""},{"help":"Provide Name and Relationship with Proposer/Applicant for up to 4 family members","type":"table","label":"Please share the details of the family members (To be filled only if family Cover is opted)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Preventive Services Selection","fields":[{"help":"Select if you want Preventive Services","type":"yes-no","label":"Preventive Services","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select all benefits required","type":"checkbox","label":"Benefits required under Preventive Services","options":["Identity Monitoring","Digital Health and Assessment","Wi-fi Scan","QR Code Scanner","Device Protection","Cyber Education and Awareness - Tips and Tricks","Emergency Guidance and Enhanced FAQs","Cyber Helpline / Incident Response","Crisis Response - Helpline Emergency assistance to block cards, SIM Cards and replace identity cards (PAN Card and Driving License)","Emergency Travel Assistance on call","Password Vault","Asset Surface Management"],"required":null,"pdf_field":""},{"help":"Select package(s) required","type":"checkbox","label":"Package required under Preventive Services","options":["Cyber safe Essential (Identity Monitoring + Cyber Education and Awareness - Tips and Tricks)","Cyber safe Core (Identity Monitoring + Cyber Education and Awareness - Tips and Tricks + Digital Health and Assessment)","Cyber safe Plus (Identity Monitoring + Cyber Education and Awareness - Tips and Tricks + Digital Health and Assessment + Cyber Helpline/Incident Response)"],"required":null,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Online Fraud and Cyber Incident History","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Have you or your family (if applicable) ever been a victim of online fraud or cyber bullying/ defamation or have any of your Computer Systems been hacked or compromised?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of the incident","type":"text","label":"If 'Yes', please provide details","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you or your family (if applicable) aware of any circumstances likely to lead to a loss or claim under this policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details","type":"text","label":"If 'Yes', please provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Nominee Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Nominee Name *","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship of Nominee with Proposer","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Nominee Date of Birth DD/MM/YYYY*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Nominee Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Nominee Email ID","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account details for claim payments","type":"text","label":"Nominee Bank Account Details","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage share for nominee; total must not exceed 100%","type":"number","label":"% share","options":[],"required":false,"pdf_field":""},{"help":"Provide name, date of birth, and relationship of appointee","type":"text","label":"Where Nominee is a minor, give details of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Payment Details","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / D.D #","options":[],"required":false,"pdf_field":""},{"help":"Enter amount drawn","type":"amount","label":"Drawn Amount","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":false,"pdf_field":""},{"help":"Enter name of bank branch or payee","type":"text","label":"Drawn To","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Bank and Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Enter account holder's name","type":"text","label":"Account Holder name","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Electronic Insurance Account (EIA) Details","fields":[{"help":"Select if you have an EIA account","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter EIA number","type":"text","label":"If Yes, please quote EIA Number","options":[],"required":false,"pdf_field":""},{"help":"Enter name of insurance repository","type":"text","label":"Please mention name of Insurance Repository","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to create an EIA account","type":"yes-no","label":"If No, do you want Us to create an EIA account for you","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter email registered with insurance repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer/applicant"},{"title":"Declarations and Signatures","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature and stamp of insurance advisor or intermediary","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":"Signature of intermediary or sales person","type":"signature","label":"Signature of Intermediary/ Sales Person","options":[],"required":true,"pdf_field":""},{"help":"Sign if proposer is person with disability","type":"signature","label":"Declaration in case the proposer/policyholder is person with disability (PWD) - Signature/Thumb impression of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative if proposer is person with disability","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant and intermediary"},{"title":"Additional Declarations","fields":[{"help":"Select Yes or No","type":"yes-no","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 if applicable","type":"yes-no","label":"Are you a Non-Profit Organization? *(only in case of an entity)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if you qualify as HNI","type":"checkbox","label":"I hereby declare that I qualify as a High Net Worth Individual (HNI), with a net worth of ₹50 crore or more","options":["Tick if applicable"],"required":false,"pdf_field":""}],"filled_by":"proposer/applicant"}],"deadlines":[],"applies_to":"Cyber Secure+ individual insurance policy proposal","attachments":["Proof of Identity (POI) and Proof of Address (POA) documents as applicable","Additional sheets if more space is needed to answer questions","Cancelled cheque for electronic fund transfer if applicable","Insurance Repository Application form if EIA account creation requested"],"declarations":["The statements made in this proposal form are true, complete and form the basis of the insurance policy.","The company’s liability starts only after acceptance of the proposal and receipt of premium.","The policy is voidable if any information is untrue, incorrect, or withheld.","Premiums must be paid from bonafide sources and not from proceeds of crime.","The proposer consents to verification of identity/address through official registries.","Policy and service communications will be sent electronically unless physical copy is requested.","No person shall offer or accept rebates on premiums except as allowed by insurer’s published prospectus.","The proposer declares if they are a politically exposed person or associated with one.","The proposer declares if they are a non-profit organization if applicable.","The proposer declares if they are a person with disability and authorizes a representative if needed."],"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/5610-cyber-secure-proposal-form"}