I/We do hereby declare that I/we have read and understood the entire text, features, disclosures, benefits, terms and conditions of the policy and I/we further declare that the information furnished above are true to the best of my/our knowledge and no material information, which may be relevant, has been withheld or not disclosed. In case any of the information above is found false during verification at a later date, the company would have the right to cancel the policy and premium amount paid will be forfeited. I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.

The quote displayed has been calculated based on the information provided by you and is subject to change in case you change the information while buying the policy. The product information, including the scopes of cover, terms, conditions, exclusions and limitations, available on the website is not intended to be exhaustive and is indicative in nature. I / We desire to insure with Zurich Kotak General Insurance Company (India) Limited in respect of the vehicle described above and confirm that the statements contained in this proposal are my/our true and accurate representations. I/we undertake that if any of the statements are found to be false or incorrect, the benefits under this policy would stand forfeited. I/We agree that this application and declaration shall be promissory and shall be the basis of the contract between me/us and Zurich Kotak General Insurance Company (India) Limited. I/We confirm that I/We have read and understood the coverages, the terms and conditions and agree to accept the company's policy of insurance along with the said conditions prescribed by the company. I/We also declare and undertake that if there is any change in information as submitted by me/us after this submission then the same would be conveyed to Zurich Kotak General Insurance Company (India) Limited immediately failing which it is agreed and understood by me/us that the benefits under the policy would stand forfeited. I/We agree to the company taking appropriate measures to capture the voice log for all such telephonic transactions carried out by me/us as required by the procedures/regulations internal or external to the company and shall not hold the company responsible or liable for relying / using such recorded telephonic conversation. I/We agree that the insurance would be effective only on acceptance of this application by the company and the payment of the requisite premium by me/us in advance. In the event of non-realisation of the cheque or non-receipt of the amount of premium by the company the policy shall be deemed cancelled ab-initio and the company shall not be responsible for any liabilities of whatsoever nature under this policy.

Declaration for No Claim Bonus
I/We declare that the rate of NCB claimed by me/us is correct and that NO CLAIM has arisen in the expiring policy period. I/We further undertake that if this declaration is found incorrect, all benefits under the policy in respect of section I of the policy will stand forfeited.

General exclusions:

The Company shall not be liable under this Policy in respect of

• any accidental loss or damage and/or liability caused sustained or incurred outside the geographical area;
• any claim arising out of any contractual liability. Please refer to policy wordings for detailed list of exclusions.

LIMITATIONS AS TO USE
The Policy covers use of the vehicle for any purpose other than

• Hire or Reward
• Carriage of goods (other than samples or personal luggage)
• Organized racing
• Pace making
• Speed testing
• Reliability Trials
• Use in connection with Motor Trade

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 (India) 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.