{"id":1578,"title":"Acko Health III - Portability Form and Annexure","purpose":"proposal","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Portability_Form_and_Annexure_Acko_Health_III_6eec88f231.pdf","sha256":"0213821ffacd25f082dd6f385c5fb8588f377722c576d02057f09949292a07e8","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders applying for health insurance portability to Acko General Insurance Limited, providing details of the existing policy and declarations related to claims and waiting periods.","notes":["Please attach all documents counter signed by the Proposer","Please fill separate annexure for member with different details"],"title":"Acko Health III - Portability Form and Annexure","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Part I - Proposer Details and Existing Insurance","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Use date format as per form instructions if any","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Nationality:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email:","options":[],"required":null,"pdf_field":""},{"help":"Include country code if applicable","type":"phone","label":"Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Alternative Email:","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Alternative Mobile No.:","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Postal code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Name of your current health insurer","type":"text","label":"Name of the Insurer:","options":[],"required":null,"pdf_field":""},{"help":"Name of your current insurance product","type":"text","label":"Name of the Product:","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under existing policy","type":"amount","label":"Sum Insured:","options":[],"required":null,"pdf_field":""},{"help":"Bonus amount accumulated","type":"amount","label":"Cumulative Bonus:","options":[],"required":null,"pdf_field":""},{"help":"List any riders or add-ons on existing policy","type":"text","label":"Add-Ons / Riders Taken:","options":[],"required":false,"pdf_field":""},{"help":"Existing policy number","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Name of the new product you want to port to","type":"text","label":"Name of the Product Proposed/Intended to apply under Portability","options":[],"required":null,"pdf_field":""},{"help":"Sum insured you want under new policy","type":"amount","label":"Sum Insured Proposed","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether Cumulative Bonus to be converted to an Enhanced Sum Insured","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain why you want to port your policy","type":"text","label":"Reason(s) for Portability","options":[],"required":null,"pdf_field":""},{"help":"Count of family members to include","type":"number","label":"Number of family members to be included in the Policy to be Ported","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part II - Waiting Period Declaration","fields":[{"help":"","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Write your consent agreeing to observe additional waiting period","type":"text","label":"If YES, please give written consent to the declaration below:","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexure II - Details of Person Proposed to be Insured and Claim Declaration","fields":[{"help":"Fill details for each insured person: Name of Insured(s), Policy No., Previous Insurer, Previous Policy(s), Sum Insured (₹), Cumulative Bonus, Exclusion(s), Loading, Start Date, End Date","type":"table","label":"Details of the person proposed to be insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Existing Policy Type","options":["Individual","Family Floater"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Any claim history of the person(s) proposed to be insured with the previous insurer(s)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List claims details for each insured person","type":"table","label":"If YES, please provide below details: Name of Insured, Claims Submitted, Year of Claim, Details of Ailment","options":[],"required":false,"pdf_field":""},{"help":"Tick to agree to these declarations","type":"checkbox","label":"If NO, then please fill the below declaration","options":["I wish to Port to (Product Name) with Acko General Insurance Limited under the applicable IRDAI regulations on Portability, and declare that the cumulative bonus accrued, as stated by me above is correct and that no claim has arisen in the expiring policy(ies).","I understand that Acko General Insurance Limited will be issuing the Policy based on the information provided and declarations submitted in the proposal form and related annexures. In case any information provided by me, in whole or part, is found to be incomplete and/or incorrect and/or fraudulent then, the Policy shall become void at the option of Acko General Insurance Limited without any refund, as stated in Policy terms and conditions."],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["The application for portability must be provided at least 30 days in advance but not earlier than 60 days of renewal date of existing policy","Any pre-policy health checkup must be completed within 7 days of intimation","Any additional information/acceptance of revised offer must be provided within 7 days from the receipt of intimation"],"applies_to":"health insurance portability proposals","attachments":["Photocopy of the existing Policy documents","Copy of all previous policy schedules with latest renewal notice","If there is a claim in existing Policy, then discharge summary, investigation and follow up report copies","If there is a past medical history, then consultation papers, prescription, investigation, treatment and report copies"],"declarations":["I hereby agree to observe the additional waiting period for the following disease(s) / treatment(s) if the exclusion period is longer than previous policy","I declare that the cumulative bonus accrued is correct and no claim has arisen in the expiring policy(ies)","I understand that if any information provided is incomplete, incorrect or fraudulent, the policy shall become void without refund"],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"1800-210-1992","label":"Customer Care Number","level":null,"hours":"Monday to Sunday: 9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/contact-us/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nLife Insurance\n/\nAcko Life Insurance Customer Care | Customer Care","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"+91 8069067215","label":"Customer Care Phone Number for PERSONS WITH DISABILITIES (PwD)","level":null,"hours":"Monday to Sunday: 9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/contact-us/","quote":"y to Sunday: 9:00 AM – 8:00 PM\nACKO Life Insurance Customer Care Phone Number for PERSONS WITH DISABILITIES (PwD)\nCall: +91 8069067215\nMonday to Sunday: 9:00 AM – 8:00 PM\nProducts\nLife insurance\nTerm insurance\n1 crore term insurance\nCompany\nAbout us\nCare","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-210-1992","label":"Grievance desk phone number","level":1,"hours":null,"applies_to":"life","source_url":"https://www.acko.com/life/customer-service/grievance-redressal/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Customer Service\n/\nACKO Life Insurance Grievan","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Ms. Komal Arawat (Grievance Redressal Officer) Acko Life Insurance Limited, 36/5 Hustlehub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Bangalore – 560102","label":"Grievance Redressal Officer postal address","level":2,"hours":null,"applies_to":"life","source_url":"https://www.acko.com/life/customer-service/grievance-redressal/","quote":null,"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/acko-life-insurance/1578-acko-health-iii-portability-form-and-annexure"}