{"id":5617,"title":"CLINICAL TRIALS LIABILITY INSURANCE 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_Clinical_Trials_Liability_Insurance_44471a09dc.pdf","sha256":"56bf3c2ecb89871ffcabc9e34d64b8be1ac1ec0d9c2133764831354665455bf1","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by proposers (companies or bodies conducting clinical trials) to apply for Clinical Trials Liability Insurance coverage from Zurich Kotak General Insurance Company.","notes":["Fill the proposal form in BLOCK LETTERS.","All details marked with * are mandatory.","The liability of the company starts only after acceptance of the proposal and receipt of premium.","Provide all information fully, accurately and correctly.","Attach additional sheets if more space is needed, indicating question number.","Use original documents for attachments as required.","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.","Politically Exposed Persons (PEPs) must be declared.","Non-profit organizations must be declared and defined as per Income-tax Act and Companies Act.","The form includes a statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938."],"title":"CLINICAL TRIALS LIABILITY INSURANCE PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Policy and Intermediary Details","fields":[{"help":"","type":"text","label":"Policy issuing office","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy servicing office","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary/Agent Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary License no /Agent code.","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Intermediary/Agent Contact No.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or intermediary/agent"},{"title":"Proposer Details","fields":[{"help":"Enter full name of the proposer","type":"text","label":"Name of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter the name of the company or body to be insured","type":"text","label":"Name of Company or Body to be Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter full address of the head office","type":"text","label":"Address of Head Office","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Communication address same as the Head Office address ?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If communication address is different, provide it here","type":"text","label":"Communication Address","options":[],"required":false,"pdf_field":""},{"help":"Describe the business activities","type":"text","label":"Description of Business","options":[],"required":true,"pdf_field":""},{"help":"Enter date of establishment","type":"date","label":"Date Established","options":[],"required":true,"pdf_field":""},{"help":"Enter policy start date","type":"date","label":"Policy Period: From","options":[],"required":true,"pdf_field":""},{"help":"Enter country where company is registered","type":"text","label":"Country of Registration","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Compliance Declaration","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Are all trials conducted in full accordance with Department of Health requirements with protocols approved by an independent Ethics Committee?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are all trials conducted in full accordance with Royal College of Physicians recommendations?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are all trials conducted in full accordance with Applicable Government Department or Medical Body or Pharmaceutical Industry Body guidelines?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are all trials conducted in full accordance with E.C. guidelines on Good Clinical Practice?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are all trials conducted in full accordance with I.C.H Harmonised Tripartite Guidelines?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If applicable, are all rights of recourse retained against Trial Sponsors and/or Product Manufacturers?","options":["YES","NO"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Adverse Events and Clinical Trials Details","fields":[{"help":"Provide full details","type":"text","label":"Give details of serious adverse events during the last 5 years resulting in death, disease or illness (physical or mental) to research subjects, and any circumstances, which have given or might give rise to a claim against you.","options":[],"required":true,"pdf_field":""},{"help":"Describe the clinical trials planned","type":"text","label":"Full description of Clinical Trials to be conducted","options":[],"required":true,"pdf_field":""},{"help":"Attach required documents for each trial","type":"attachment","label":"For each trial please attach a copy of: a) Protocol (or summary thereof) or Ethics Committee Submission b) Volunteer Consent Form and/or Patient Information (as appropriate) c) Any Hold Harmless Agreement/Contract indemnities with other parties (if applicable)","options":[],"required":true,"pdf_field":""},{"help":"Fill details for each trial performed in last 12 months","type":"table","label":"Summary of Trials Performed in the last 12 months (Date Commenced, Trial Title/Description, Phase, No. of Research Subjects, Current Status)","options":[],"required":true,"pdf_field":""},{"help":"Fill details for each trial planned in next 12 months","type":"table","label":"Summary of Trials Planned in the next 12 months (Date Commenced, Trial Title/Description, Phase, No. of Research Subjects, Current Status)","options":[],"required":true,"pdf_field":""},{"help":"Enter indemnity limit per subject","type":"amount","label":"Please state Limits of Indemnity for which a quotation is required or local currency equivalent: Per each Clinical Trial Subject","options":[],"required":true,"pdf_field":""},{"help":"Enter total coverage amount per annum","type":"amount","label":"Total Coverage Per Annum","options":[],"required":true,"pdf_field":""},{"help":"Enter higher limit if applicable","type":"amount","label":"If higher, please state","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration of Questionnaire Completion","fields":[{"help":"Enter position or designation","type":"text","label":"Position of person completing the Questionnaire","options":[],"required":true,"pdf_field":""},{"help":"Signature of the person completing the questionnaire","type":"signature","label":"Signed","options":[],"required":true,"pdf_field":""}],"filled_by":"person completing questionnaire"},{"title":"Bank Account and Payment Details","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Details as per premium cheque to be used for electronic fund transfer / Cancelled cheque submitted of other bank","options":[],"required":false,"pdf_field":""},{"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 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 date of payment","type":"date","label":"Date","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 reference number for card payments","type":"text","label":"Transaction Reference No","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date for card payments","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Do you have an EIA Account","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter EIA number if applicable","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 Yes or No","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 ID registered with insurance repository","type":"email","label":"Email id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Agree to declaration","type":"checkbox","label":"I / We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my / our knowledge and belief and I / We hereby agree that this declaration shall form the basis of the contract between me / us and the \"Zurich Kotak General Insurance Company (India) Limited\"","options":[],"required":true,"pdf_field":""},{"help":"Tick if physical copy is desired","type":"checkbox","label":"I / We would still want to receive a physical copy of the policy","options":[],"required":false,"pdf_field":""},{"help":"Consent for KYC verification","type":"checkbox","label":"I / We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through Central KYC Registry or Goods and Service Tax Portal or Ministry Of Corporate Affairs Portal or National Securities Depository Limited portal for the purpose of undertaking KYC","options":[],"required":true,"pdf_field":""},{"help":"Confirm AML compliance","type":"checkbox","label":"AML DECLARATION: I / We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been /will be paid out of proceeds of crime related to any of the offence listed in Prevention of Money Laundering Act, 2002","options":[],"required":true,"pdf_field":""},{"help":"Select organization type","type":"choice","label":"Type of Organization making the payment","options":["Limited Company","Government Organization","Non-Government Organization (NGO)","Society","Trust","Partnership","International Organization","Co-operatives","Section 25 Company","Others"],"required":true,"pdf_field":""},{"help":"Select Yes or No","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":"Select Yes or No","type":"yes-no","label":"Are you a Non-Profit Organization? (only in case of an entity)","options":["Yes","No"],"required":false,"pdf_field":""},{"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 and stamp here","type":"signature","label":"Signature and Stamp of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration for Agent","fields":[{"help":"Proposer's signature","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Agent's signature and stamp","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":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"agent/intermediary"},{"title":"Vernacular Declaration","fields":[{"help":"Proposer's signature or thumb impression","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Agent's signature","type":"signature","label":"Signature of Intermediary/ Sales Person","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"agent/intermediary"}],"deadlines":[],"applies_to":"Clinical Trials Liability Insurance","attachments":["Protocol Details of the studies","Patient Consent Forms","Compensation agreement/basis if No fault Compensation is selected","Protocol (or summary thereof) or Ethics Committee Submission for each trial","Volunteer Consent Form and/or Patient Information for each trial","Any Hold Harmless Agreement/Contract indemnities with other parties (if applicable)"],"declarations":["The statements made in this Proposal Form are true and form the basis of the contract.","Consent is given to verify identity/address proof through specified government portals for KYC.","All premiums are paid from bonafide sources and not from proceeds of crime under the Prevention of Money Laundering Act.","The insurance company may cancel the contract if found guilty under money laundering laws.","The proposer agrees to receive policy and service communication in soft copy unless physical copy is requested.","The agent declares that the policy features and terms have been explained to the proposer.","The vernacular declaration confirms the proposer understood the form contents in their language."],"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/5617-clinical-trials-liability-insurance-proposal-form"}