{"id":1004,"title":"Proposal Form","purpose":"proposal","insurer":{"slug":"new-india-assurance","name":"The New India Assurance Company Limited"},"source_pdf":"https://www.newindia.co.in/assets/docs/know-more/health/paripoorna-ayush-bima/PMAB%20Proposal%20Form.pdf","sha256":"bcacf866949535045c348910ad9a788c6227eb2724033347960c7f7c1e07066b","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for a health insurance policy under the Paripoorna Mediclaim Ayush Bima scheme. The proposer fills it with personal, family, medical, and insurance details.","notes":["Proposal form must be completed truthfully and fully with all material facts disclosed.","For persons above 60 years or with adverse medical history applying for first time, pre-acceptance health checkup is mandatory.","Fresh proposal and medical checkup required if there is a break in insurance cover or sum insured enhancement.","Non-disclosure, misleading information, fraud or non-cooperation will nullify policy cover.","Policy is not on risk until accepted by company and premium fully paid.","Use stamp size photographs for insured persons.","Cancelled cheque must bear account holder’s name or provide bank attestation or bank statement copy.","Policy documents are sent by default to registered email; physical copy available on request.","Proposer’s name in policy must exactly match bank account name for NEFT payments."],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Details","fields":[{"help":"","type":"text","label":"Name of the Proposer:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for Correspondence Landmark/Area/City/Town:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin:","options":[],"required":true,"pdf_field":""},{"help":"Mandatory for retirees","type":"text","label":"CGHS Card Number:","options":[],"required":null,"pdf_field":""},{"help":"Validity of CGHS card","type":"date","label":"Validity Date:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee ID / PPO No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"CGHS City / Wellness Centre:","options":[],"required":null,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Occupation:","options":["In- Service","Retired"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Ministry / Department / Office:","options":[],"required":null,"pdf_field":""},{"help":"This is a Floater Policy; sum insured shared among all members","type":"choice","label":"Sum Insured Selected (Rs.)","options":["10 Lakhs","20 Lakhs"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Co-pay selected:","options":["70:30 (70% insurer / 30% insured)","50:50 (50% insurer / 50% insured)"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Term and Period of Insurance","fields":[{"help":"Fixed as 1 Year","type":"text","label":"Term of Insurance","options":[],"required":true,"pdf_field":""},{"help":"Start date of policy","type":"date","label":"Period of Insurance: From","options":[],"required":true,"pdf_field":""},{"help":"End date of policy","type":"date","label":"To","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer and Nominee Details","fields":[{"help":"","type":"date","label":"Date of Birth of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender (M/F/T)","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Educational Qualifications","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id","options":[],"required":null,"pdf_field":""},{"help":"10-digit mobile number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Annual family income","type":"number","label":"Family Income","options":[],"required":null,"pdf_field":""},{"help":"Select type of identity proof","type":"choice","label":"Nature of Id","options":["PAN Card","Voter Id","Passport","Aadhar Card","Any other"],"required":null,"pdf_field":""},{"help":"Number of selected ID","type":"text","label":"Id Card No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN Card No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"GST No (If applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee 1 Name (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"DOB of Nominee 1","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with Nominee 1","options":[],"required":true,"pdf_field":""},{"help":"Percentage share of nominee","type":"number","label":"% Share Nominee 1 is entitled to","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nominee 2 Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"DOB of Nominee 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Nominee 2","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"% Share Nominee 2 is entitled to","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee 3 Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"DOB of Nominee 3","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Nominee 3","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"% Share Nominee 3 is entitled to","options":[],"required":false,"pdf_field":""},{"help":"Mandatory if any nominee is minor","type":"text","label":"Appointee Name*","options":[],"required":null,"pdf_field":""},{"help":"Mandatory if any nominee is minor","type":"text","label":"Relationship with Minor","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Family Physician Details","fields":[{"help":"Provide full contact details","type":"text","label":"Name, Address & Contact No. of Family Physician","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Registration number of physician","type":"text","label":"Reg. No","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Insurance Details","fields":[{"help":"If previously insured","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insurance Scheme","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Duration of previous insurance","type":"text","label":"Period of cover","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is there any claim under the previous Insurance (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of claim if any","type":"text","label":"If Yes, please give the details of such claim and amount received/receivable","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"ABHA Number and Consent","fields":[{"help":"Provide ABHA ID if available","type":"text","label":"ABHA NUMBER/ABHA ID","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium charged, either by us or by any other Insurer. If so, give details:","options":[],"required":null,"pdf_field":""},{"help":"Policy documents by default sent to registered email","type":"checkbox","label":"Please Tick if you wish to receive the physical copy","options":["Tick if yes"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Modern Treatment Rider and Discount","fields":[{"help":"15% of Base Premium applicable if Yes","type":"choice","label":"Do you want to opt for Modern Treatment Rider","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Discount in lieu of CB opted?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical History","fields":[{"help":"Answer for all members","type":"yes-no","label":"Are all the members proposed for insurance in good health while proposing for this insurance? (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List name and nature of illness/pre-existing diseases","type":"table","label":"If No, give details of the Illnesses/ diseases for each member","options":[],"required":null,"pdf_field":""},{"help":"Name, nature of illness/disease/injury & treatment, date first treatment taken, treatment status, attending medical practitioner details","type":"table","label":"Have any of the persons proposed for insurance suffered from any illness/disease or had an accident in the past? If so, give details as under:","options":[],"required":null,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"Please give details of any knowledge or any positive existence or presence of any ailment, sickness or injury, which may require medical attention?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"Are there any additional facts affecting the proposed Insurance, which should be disclosed to insurers?","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable conditions","type":"checkbox","label":"Do any of the persons proposed suffer from any of the following conditions (tick if applicable): Diabetes, Hypertension, Cardiac Disease, Asthma, Kidney Disease, Liver Disease, Cancer, Neurological Disorder, Joint Disorders, Any other condition (please specify):","options":["Diabetes","Hypertension","Cardiac Disease","Asthma","Kidney Disease","Liver Disease","Cancer","Neurological Disorder","Joint Disorders","Any other"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Lifestyle & Habits","fields":[{"help":"","type":"yes-no","label":"Do you consume tobacco in any form?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you consume alcohol?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, specify","type":"yes-no","label":"Any other material information relevant to health risk?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Identification & KYC Documents","fields":[{"help":"Attach all mandatory documents","type":"checkbox","label":"Attach / upload self-attested copies of the following:","options":["CGHS Card of Proposer (Mandatory)","Aadhaar Card / PAN Card (Mandatory)","Employee ID / PPO Document","Proof of Address","Proof of Age","Recent Photograph of Proposer and the member proposed to be insured"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"NEFT Details","fields":[{"help":"","type":"text","label":"Name (As in Bank Account)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Branch","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"MICR No","options":[],"required":true,"pdf_field":""},{"help":"11-digit IFSC code for NEFT","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm bank details","type":"signature","label":"Proposer/Policy holder’s signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Details","fields":[{"help":"","type":"choice","label":"Mode of Payment","options":["Online (UPI / Net Banking / Debit Card / Credit Card)","Cheque","Cash"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign to confirm declarations","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration","fields":[{"help":"Person explaining the form if proposer is illiterate or signed in vernacular","type":"text","label":"Name of the Translator","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Translator","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"translator"}],"deadlines":[],"applies_to":"Floater health insurance policy under Paripoorna Mediclaim Ayush Bima","attachments":["Self-attested copies of CGHS Card of Proposer","Aadhaar Card / PAN Card","Employee ID / PPO Document","Proof of Address","Proof of Age","Recent Photograph of Proposer and members proposed to be insured","Cancelled cheque for NEFT","Photographs of Insured Persons (stamp size)"],"declarations":["The information given is true and complete to the best of knowledge.","All material facts including pre-existing diseases and medical history are disclosed.","Policy operates independently of CGHS benefits.","Policy terms and conditions including waiting periods, co-payment, exclusions, sub-limits, and claim procedures are understood and agreed.","Policy commences only after acceptance by insurer and receipt of premium.","Insurer is authorized to obtain medical records and relevant data for underwriting and claims.","Suppression or misrepresentation of material facts may result in policy cancellation or claim denial.","Consent given to insurer to seek medical information from doctors, hospitals, employers, and other insurers for underwriting and claims.","Consent given to insurer to share proposal and medical records with government and regulatory authorities."],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"1800-209-1415","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/","quote":"Login\nCustomer\nIntermediary\nToll Free :\n1800-209-1415\nAbout Us\nOverview\nProfile\nManagement\nFinancials\nWorkforce\nOur Offices\nIntermediary\nInvestors\nProducts\nAll Products\nBase","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@newindia.co.in","label":"Grievance Redressal Officer Ms. V. Akila","level":1,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/grievance","quote":"dressal Officer\nName\nDesignation\nEmail ID\nLandline No\nMs. V. Akila\nDeputy General Manager & Grievance Redressal Officer\ngro@newindia.co.in\n022-2270 8316\nKnow Your Customer Care Officers\nNote :\nPlease select type \"City Name or Policy No\" to know your Grievanc","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customercare.ho@newindia.co.in","label":"Customer Service Desk Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/STANDARD%20FORM%20FOR%20TWO%20WHEELERS%20BASE%20PACKAGE%20POLICY.pdf","quote":"complaint, please free to call our 24X7 Toll free number 1800-209-1415 or you may email to the customer service desk at customercare.ho@newindia.co.in. After investigating the matter internally and subsequent closure, we will send our response.\nYou can also approach the","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-1415","label":"Toll Free","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/grievance","quote":"Grievance New India Assurance Co. Ltd.\nLogin\nCustomer\nIntermediary\nToll Free :\n1800-209-1415\nAbout Us\nOverview\nProfile\nManagement\nFinancials\nWorkforce\nOur Offices\nIntermediary\nInvestors\nProducts\nAll Products\nBase","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.newindia.co.in/portal/readMore/Grievances","label":"Customer Grievance Redressal Website","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"sal and Policyholders Protection | ln case of any grievance the insured person may contact the company through Website: https://www.newindia.co.in/portal/readMore/Grievances Toll free: 1800-209-1415 Visit the Servicing Branch mentioned in the policy Document Insurance Ombudsman If You are sti","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/new-india-assurance/1004-proposal-form"}