{"id":1618,"title":"Customer Declaration Form (CDF and SI Form for Non-ICICI BANK channel customer ver 4.0.4)","purpose":"service","insurer":{"slug":"prudential-hcl-health-insurance","name":"Prudential HCL Health Insurance Limited"},"source_pdf":"https://www.icicilife.com/content/dam/icicipru/download-centre/applicationforms/CDF&ECS_Nonibank_ver_4.0.4.pdf","sha256":"d5c60a519228cca22ea7434dbfba1c98e1199e782631931ceb1759cc919d012d","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for customers applying for ICICI Prudential Life Insurance policies online to declare their understanding and consent, and to authorize Electronic Clearing Service (ECS) or Direct Debit for premium payments. It is filled by the policy applicant and account holders.","notes":["Applicants signing in vernacular language must attach a vernacular declaration with witness confirmation.","ECS/Direct Debit request will be rejected if bank details do not match records or cancelled/photocopied cheque is not attached.","In case of Current Account, affix Proprietary Firm / Company stamp on the mandate.","Premiums are payable for the entire policy term; life cover ceases if renewal premiums are not paid when due.","If ECS/Direct Debit transaction is delayed or not effected due to incomplete or incorrect information, the company is not responsible.","A charge of ₹150 per transaction will be recovered if payment is not honored on the due date.","Use block letters to fill the form.","All policy related communication will be sent only to addresses in India and Dubai."],"title":"Customer Declaration Form (CDF and SI Form for Non-ICICI BANK channel customer ver 4.0.4)","submit":{"to":"ICICI Prudential Life Insurance Company Ltd.","how":"","address":""},"purpose":"service","sections":[{"title":"Applicant Declaration and Application Details","fields":[{"help":"Write your name and the product name(s) applied for online.","type":"text","label":"I/We____________________________________________________________ request you to process the above mentioned Application Number(s) for ____________________________________ submitted online by me/ us on ICICI Prudential's website www.iciciprulife.com.","options":[],"required":null,"pdf_field":""},{"help":"Name of the person who filled the application form in your presence.","type":"text","label":"Mr./Ms._________________________________________________________, has duly filled the details in the application form in my/our presence and in accordance with the information provided by me/us.","options":[],"required":null,"pdf_field":""},{"help":"List the combination products if applicable.","type":"text","label":"I have opted for the Combination Solution comprising products like ______________________ ,   ______________________ and  ______________________","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount paid as first premium.","type":"amount","label":"I have made the payment of `  ______________________  towards the first premium deposit for the above products.","options":[],"required":false,"pdf_field":""},{"help":"Enter your application number.","type":"text","label":"Application No.","options":[],"required":true,"pdf_field":""},{"help":"Enter the amount in rupees.","type":"amount","label":"Amount (`)*","options":[],"required":true,"pdf_field":""},{"help":"Enter the policy start date.","type":"date","label":"Start Date","options":[],"required":true,"pdf_field":""},{"help":"Enter the policy end date.","type":"date","label":"End Date","options":[],"required":true,"pdf_field":""},{"help":"Name of your bank.","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Your bank account number.","type":"text","label":"CBS Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select your bank account type.","type":"choice","label":"Account Type:","options":["Current Account","Saving Account","Cash Credit Account"],"required":true,"pdf_field":""},{"help":"Enter the name as per bank records.","type":"text","label":"Name of Account Holder (as mentioned in Bank Account)","options":[],"required":true,"pdf_field":""}],"filled_by":"applicant"},{"title":"Bank ECS/Direct Debit Authorization","fields":[{"help":"Tick to authorize ECS debit.","type":"checkbox","label":"I hereby instruct the bank to debit my account and pay to ICICI Prudential Life Insurance Co. Ltd. as per the demand sent by ICICI Prudential Life Insurance Co. Ltd.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Specify premium payment frequency.","type":"text","label":"Frequency","options":[],"required":true,"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 if different from proposer.","type":"signature","label":"Life Assured’s Signature (If different from Proposer)","options":[],"required":false,"pdf_field":""},{"help":"Applicant must sign here.","type":"signature","label":"Applicant’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Primary bank account holder must sign.","type":"signature","label":"Primary Account Holder’s Signature","options":[],"required":true,"pdf_field":""},{"help":"If applicable, joint account holder 1 signs.","type":"signature","label":"Joint Account Holder’s Signature 1","options":[],"required":false,"pdf_field":""},{"help":"If applicable, joint account holder 2 signs.","type":"signature","label":"Joint Account Holder’s Signature 2","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant and bank account holders"},{"title":"Declarations and Consents","fields":[{"help":"Confirm your residence status.","type":"checkbox","label":"I hereby declare and confirm that I am applying for this policy while I am in India /Dubai and I reside in country as indicated in the application form appended hereby.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm eligibility to buy policy.","type":"checkbox","label":"I hereby declare and confirm that I am allowed to procure/obtain life insurance policies offered by ICICI Prudential Life Insurance Company Ltd.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm no legal restrictions.","type":"checkbox","label":"I hereby declare and confirm that I am not prohibited/ precluded by the laws of any country/jurisdiction to avail life insurance policies from insurance companies registered in India.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm understanding and suitability.","type":"checkbox","label":"I/We have understood the features of the product and believe it would be suitable for me/our insurance objective.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm receipt of key documents.","type":"checkbox","label":"I/We confirm that I/we have received and understood the Electronic Benefit Illustration / Key feature document","options":["Agree"],"required":true,"pdf_field":""},{"help":"Consent to sharing KYC information.","type":"checkbox","label":"I/We am/are aware and agree that the Company has/may have tie-ups with various financial institutions, credit rating agencies, CERSAI* and other such entities to enable sharing/collecting/validating my/our KYC related documents/information.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm accuracy of information.","type":"checkbox","label":"I hereby declare that the particulars given are true, correct and complete.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Consent to ECS/Direct Debit premium payment.","type":"checkbox","label":"I wish to avail of the Direct Debit facility and hereby express my unconditional consent to debit premium of my policy referred to above through participation in Electronic Clearing System (ECS) / Direct Debit.","options":["Agree"],"required":true,"pdf_field":""}],"filled_by":"applicant"}],"deadlines":[],"applies_to":"","attachments":["Age/Address/Identity/Income Proof and photograph as applicable","Cancelled/photocopied cheque"],"declarations":["Applicant confirms applying while residing in India or Dubai as declared.","Applicant confirms eligibility to obtain life insurance from ICICI Prudential.","Applicant confirms no legal prohibition to avail Indian life insurance policies.","Applicant confirms understanding and suitability of the product.","Applicant confirms receipt and understanding of Electronic Benefit Illustration / Key feature document.","Applicant consents to sharing and validation of KYC information with related entities.","Applicant declares all particulars given are true, correct and complete.","Applicant consents unconditionally to ECS/Direct Debit premium payments."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customersupport@prudentialhealth.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/raise-grievance","quote":"7th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth Protect\nPRUHealth Guardian\nTools &","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 268 2000","label":"Customer Support Toll-Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/raise-grievance","quote":"704 to 1708, 17th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"resolutiondesk@prudentialhealth.in","label":"Grievance Redressal Team Email","level":2,"hours":null,"applies_to":"health","source_url":"https://storage.googleapis.com/pruinhlth-prod-prd-yoh0kt-asia-south1-bkt-pinnacle-corp-p2/pinnacle/Prospectus_PRU_Health_Guardian_af8a9e6ecb/Prospectus_PRU_Health_Guardian_af8a9e6ecb.pdf","quote":"s not satisɰed with the resolution provided, they may escalate the matter by writing to the Grievance Redressal Team at resolutiondesk@prudentialhealth.in In case the Insured Person/Policyholder is still not satisɰed with the resolution provided by the Grievance Redressal T","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Prudential HCL Health Insurance Ltd. Unit No. 501, 5th Floor, Building No. 03 Gigaplex IT / ITES SEZ, Plot No. IT-5 Airoli (W), Navi Mumbai Maharashtra – 400708","label":"Grievance Redressal Officer Postal Address","level":3,"hours":null,"applies_to":"health","source_url":"https://storage.googleapis.com/pruinhlth-prod-prd-yoh0kt-asia-south1-bkt-pinnacle-corp-p2/pinnacle/Prospectus_PRU_Health_Guardian_af8a9e6ecb/Prospectus_PRU_Health_Guardian_af8a9e6ecb.pdf","quote":"QVb6HQLRUFLWL]HQVPD\\ZULWHWRXVDWVHQLRUFLWL]HQ#SUXGHQWLDOKHDOWKLQ\n• &RXULHUb:ULWHWRRXU+HDG2ɲFHDWWKHDGGUHVVPHQWLRQHGbelow:\nPrudential HCL Health Insurance Ltd. Unit No. 501, 5th Floor, Building No. 03 Gigaplex IT / ITES SEZ, Plot No. IT5 Airoli (W), Navi Mumbai Maharashtra ȣ 400708 The Insured Person/Policyholder may also approach any of the Companyȧs branches with the details of the grievance. If th","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/prudential-hcl-health-insurance/1618-customer-declaration-form-cdf-and-si-form-for-non-icici-bank-channel-customer-ve"}