13,299

Declaration
I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of these other persons.
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy will come into force only after full payment of the premium chargeable.
I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before communication of the risk acceptance by the company.
I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

Go Green/ Go Paperless

I would like to protect and contribute in conserving the environment and help save paper by authorizing Zurich Kotak General Insurance Company Limited to send all my policy and service related communication in soft copy to the email id as mentioned in the application form.

Pls note:

• Issuance of policy is subject to receipt of premium, in case the premium is not received, the policy shall be void ab-initio.
• The policy is issued basis the details provided by you. In case of any non-disclosure, the policy is liable to be cancelled.
• The policy is subject to the underwriting guidelines of the Company.
• Based on your health declaration(s), you are likely to be contacted by Zurich Kotak General Insurance for additional documents and a pre-policy medical check-up, if applicable.
• Analysis of your medical reports will be done before issuing a policy.
• Kindly note that we cannot issue a policy until the prescribed formalities are completed, inspite of having received your payment.
• In case of refund of premium, the same would be given in the account/card from which the premium was received.
• Online premium payment should be made by the policyholder himself. No third party payment should be made using this mode of payment
• Toll Free: 1800 266 4545 Email: care@zurichkotak.com Website: www.zurichkotak.com
• Registered Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai- 400063. Maharashtra, India. CIN: U66000MH2014PLC260291. IRDAI Regn. No 152.
• For more details on risk factors, terms, conditions, coverages and exclusions, please read the sales brochure carefully before concluding a sale
• Tax benefits under Section 8- of the Income Tax are subject to change in the applicable tax laws. Please consult your financial advisor for more details.

STATUTORY WARNING
PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938 as amended)
1) No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the Policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
2) Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to Ten Lakhs Rupees.

Declaration
I have understood the difference between the expiring policy with M/S._ and the proposed policy with M/S Zurich Kotak General Insurance Company Limited especially relating to pre existing disease exclusions, time bound exclusions and other terms and conditions. I also give my consent to the proposed insurer to access my previous policy and claims details through my previous insurers/ Insurance Information Bureau of India. I understand in the event of my renewal of existing policy with the present insurer also the new policy now issued by the new Insurer will not be treated as a ported policy. In case of any change in the information furnished in the proposal form (attached herewith) regarding member(s) details/ health status and claims subsequent to the date of this application, I shall communicate the same to the insurer before inception of this policy.