{"id":5613,"title":"CONSENT-CUM-DECLARATION FORM","purpose":"proposal","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Application_Form_Zurich_Kotak_Pradhan_Mantri_Suraksha_Bima_Yojana_10eaee2af0.pdf","sha256":"9c7b435148ef56aa6d06b8322e471285712bbda64c587dde1aefb343f98ff33d","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is to give consent and apply for membership under the Pradhan Mantri Suraksha Bima Yojana accidental insurance scheme. It is filled by the account holder who wishes to enroll.","notes":["Risk cover starts from the date of auto-debit of premium from the subscriber's account.","Permanent disability definitions and claim amounts are explained in the notes section.","Nominee details must be provided; if nominee is minor, guardian details must be provided.","KYC document copy must be enclosed as proof of identity.","Confirmed verification of applicant’s details and signature will be done by the Bank/Post Office official."],"title":"CONSENT-CUM-DECLARATION FORM","submit":{"to":"Bank / Post Office branch where account is held","how":"in person","address":""},"purpose":"proposal","sections":[{"title":"Consent and Declaration","fields":[{"help":"Write the name of the insurer administering the scheme","type":"text","label":"I hereby give my consent to become a member of ‘Pradhan Mantri Suraksha Bima Yojana’ of ………… (Name of Insurer)","options":[],"required":true,"pdf_field":""},{"help":"Authorize debit of Rs. 20 as premium","type":"amount","label":"I hereby authorize you to debit my Account with your Branch with Rs. 20/- (Rupees twenty only), towards premium of accidental insurance cover@ of Rs two lakhs under PMSBY","options":[],"required":true,"pdf_field":""},{"help":"Authorize future annual premium deductions","type":"amount","label":"I further authorize you to deduct in future after 25th May and not later than on 1st of June every year until further instructions, an amount of Rs.20/- or any amount as decided from time to time","options":[],"required":true,"pdf_field":""},{"help":"Confirm no other bank/post office debits premium","type":"yes-no","label":"I have not authorized any other Bank / Post Office to debit premium in respect of this scheme","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Confirm understanding and consent","type":"yes-no","label":"I have read and understood the Scheme rules and I hereby give my consent to become a member of the Scheme","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Write the name of the insurer to share personal details with","type":"text","label":"I authorize the Bank /Post Office to convey my personal details, given below, as required, regarding my admission into the group insurance scheme to ……….. (Name of Insurer)","options":[],"required":true,"pdf_field":""}],"filled_by":"account holder"},{"title":"Identity Proof and Nominee Details","fields":[{"help":"Select one KYC document enclosed","type":"choice","label":"I hereby enclose a copy of my ------------------as proof of my identity (KYC*)","options":["AADHAAR card","Electoral Photo Identity Card (EPIC)","MGNREGA card","Driving License","PAN card","Passport"],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Date of Birth of nominee","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to nominee","type":"text","label":"Relationship of nominee with the account holder","options":[],"required":true,"pdf_field":""},{"help":"Provide guardian details if nominee is minor","type":"text","label":"Name and address of Guardian / appointee (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Specify guardian's relationship to nominee","type":"text","label":"Relationship of the guardian / appointee with the nominee","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's mobile number","type":"phone","label":"Mobile number of nominee","options":[],"required":false,"pdf_field":""},{"help":"Enter guardian's mobile number if applicable","type":"phone","label":"Mobile number of guardian / appointee","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's email id","type":"email","label":"Email id of nominee","options":[],"required":false,"pdf_field":""},{"help":"Enter guardian's email id if applicable","type":"email","label":"Email id of guardian / appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"account holder"},{"title":"Personal and Account Details","fields":[{"help":"Enter full name as per bank records","type":"text","label":"Name of the account holder","options":[],"required":true,"pdf_field":""},{"help":"Enter father's or husband's name","type":"text","label":"Father’s / husband’s name","options":[],"required":true,"pdf_field":""},{"help":"Enter full residential address","type":"text","label":"Address of the account holder","options":[],"required":true,"pdf_field":""},{"help":"Enter city, town or village name","type":"text","label":"Name of City / town / village","options":[],"required":true,"pdf_field":""},{"help":"Enter district name","type":"text","label":"Name of District","options":[],"required":true,"pdf_field":""},{"help":"Enter state name","type":"text","label":"Name of State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile number of account holder","options":[],"required":true,"pdf_field":""},{"help":"Enter bank or post office account number","type":"text","label":"Bank / Post Office Account No.","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code of Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter name of KYC document submitted","type":"text","label":"Name of the KYC document submitted","options":[],"required":true,"pdf_field":""},{"help":"Enter KYC document ID number","type":"text","label":"KYC Id number","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number if available","type":"text","label":"PAN Number, if available","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhaar number if available","type":"text","label":"AADHAAR Number, if available","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"Enter email id","type":"email","label":"E-mail Id","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you have any disability","type":"yes-no","label":"Whether suffering from any disability","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of disability if applicable","type":"text","label":"If yes, details thereof","options":[],"required":false,"pdf_field":""}],"filled_by":"account holder"},{"title":"Signature and Date","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"account holder"}],"deadlines":[],"applies_to":"Pradhan Mantri Suraksha Bima Yojana accidental insurance cover","attachments":["Copy of KYC document (AADHAAR card or Electoral Photo Identity Card (EPIC) or MGNREGA card or Driving License or PAN card or Passport)"],"declarations":["I hereby give my consent to become a member of the scheme and authorize premium debit.","I have not authorized any other bank/post office to debit premium for this scheme.","I have read and understood the scheme rules and consent to membership.","The information provided is true and forms the basis of admission; false information will lead to cancellation."],"dropped_labels":1},"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/5613-consent-cum-declaration-form"}