{"id":1623,"title":"CUSTOMER DECLARATION AND ASSIGNMENT FORM","purpose":"proposal","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_for_Loan_Protect_Plus_v4.2.pdf","sha256":"ed502b0e797080e1e4edd1bf1412111a596065e714d9bd4984648d62c6f777a3","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for applicants of the ICICI Prudential Loan Protect Plus policy to declare their understanding and agreement to the application and assignment terms. It is filled by the policy applicant (proposer) and life assured.","notes":["Do not fill the declaration if Application Number field(s) is/are blank or edited.","Applicants signing in vernacular language or affixing thumb impression must attach a vernacular declaration and have a witness confirm explanation of the form.","Assignment endorsement is subject to issuance of the policy.","For combination sales, if any product application is rejected, all applications in the combination are rejected and premium refunded with deductions.","Policy related communication for NRI/PIO/Foreign Nationals will be sent only to addresses in India, Bahrain, and Dubai.","Use the exact Application Number as provided; do not edit.","Witness signature is mandatory for assignment."],"title":"CUSTOMER DECLARATION AND ASSIGNMENT FORM","submit":{"to":"ICICI Prudential Life Insurance Company Ltd.","how":"","address":""},"purpose":"proposal","sections":[{"title":"Application Number","fields":[{"help":"Enter the application number as provided; do not leave blank or edit.","type":"text","label":"Application Number","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Customer Declaration","fields":[{"help":"Fill in your full name and purpose of application as applicable.","type":"text","label":"I/We ___________________________________________________________________________________________________________________________________ request you to process the above mention Application Number for _________________________________________________________________________________________ submitted online by me/us on ICICI Prudential’s website www.iciciprulife.com, along with assignment form","options":[],"required":true,"pdf_field":""}],"filled_by":"applicant"},{"title":"Declarations and Consents","fields":[{"help":"Confirm you have read and understood the product details.","type":"checkbox","label":"I/We confirm that I/we have read relevant documentation/information and have understood the product features and benefits.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm voluntary submission of application.","type":"checkbox","label":"I/We agree and confirm that I/we have submitted the application to buy this product of my/our own accord.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm accuracy of application details.","type":"checkbox","label":"I/We hereby confirm that I/We have duly filled the details in the application form or they have been filled in my/our presence and in accordance with the information provided by me/us.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm truthfulness of information provided.","type":"checkbox","label":"I/We acknowledge that the information stated in the above application form is true and correct and I/we have duly checked and verified the same.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Confirm submission of required documents.","type":"checkbox","label":"I/We am/are submitting the requisite documents (Age/Address/Identity/Income Proof and photograph) as applicable for further processing of this application.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Consent to sharing and verification of KYC documents.","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":"Consent to sharing information for policy processing and legal compliance.","type":"checkbox","label":"I/We also understand and confirm that my/our contact details or other information, may be shared on confidential basis, within the ICICI group and/or with any service provider/third party agency with whom the Company has tie-ups/arrangements, for processing of this proposal or servicing of the resulting policy, and may also be shared if required or permitted by any law, rule or regulation or at the request of any public or regulatory authority or if required for the purpose of preventing fraud.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Consent to PAN and KYC verification via CERSAI CKYC portal.","type":"checkbox","label":"I/we also agree that the PAN details and other information provided by me/us in the application form maybe used by the Company to download/verify my/our KYC documents from the CERSAI* CKYC portal for processing your application.","options":["Agree"],"required":true,"pdf_field":""},{"help":"Consent for ICICI Bank to share your details if applicable.","type":"checkbox","label":"I/we am/are an existing customer(s) of ICICI Bank Limited and give my/our consent to ICICI Bank to share my/our details for the purpose of my/our application/renewal for insurance policy.","options":["Agree"],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"NRI/PIO/Foreign National Declarations","fields":[{"help":"Confirm your residence and location at time of application.","type":"checkbox","label":"I hereby declare and confirm that I am applying for this policy while I am in India/Bahrain/Dubai and I reside in the country as indicated in the application form appended.","options":["Agree"],"required":false,"pdf_field":""},{"help":"Confirm eligibility to obtain insurance policies.","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":false,"pdf_field":""},{"help":"Confirm no legal prohibition to avail insurance policies.","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":false,"pdf_field":""}],"filled_by":"applicant if applicable"},{"title":"Combination Sales Declaration","fields":[{"help":"List the combination products chosen.","type":"text","label":"I have opted for the Combination Solution comprising products like ___________________________ , ___________________________ and  ___________________________ , as it would assist me in planning my finances.","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount paid as first premium.","type":"amount","label":"I have made the payment of Rs.  ______________________  towards the first premium deposit for the above products.","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant if applicable"},{"title":"Notice of Assignment for ICICI Pru Loan Protect Plus Policy","fields":[{"help":"Enter the name of the financial institution (Assignee).","type":"text","label":"I understand and agree to assign the policy to the <         > (hereinafter referred to as the “Assignee”) from whom I have availed loan.","options":[],"required":true,"pdf_field":""},{"help":"Sign here as the applicant.","type":"signature","label":"Applicant’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Life assured signs here if different from applicant.","type":"signature","label":"Life Assured’s Signature (if different from proposer)","options":[],"required":false,"pdf_field":""},{"help":"Witness must sign if assignment is done.","type":"signature","label":"Witness Signature (applicable for assignment)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD MM YYYY format.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"applicant"}],"deadlines":[],"applies_to":"applicants of ICICI Prudential Loan Protect Plus policy with assignment","attachments":["Age Proof","Address Proof","Identity Proof","Income Proof","Photograph","Vernacular declaration (if applicant signs in vernacular language or thumb impression)"],"declarations":["Applicant confirms reading and understanding product features and benefits.","Applicant confirms voluntary submission of application.","Applicant confirms accuracy and truthfulness of application information.","Applicant confirms submission of required documents.","Applicant consents to sharing and verification of KYC documents with financial institutions and agencies.","Applicant consents to sharing information within ICICI group and with third parties for policy processing and legal compliance.","Applicant consents to PAN and KYC verification via CERSAI CKYC portal.","Existing ICICI Bank customers consent to sharing details for insurance application or renewal.","NRI/PIO/Foreign Nationals confirm residence, eligibility, and legal compliance for insurance policies.","Applicant agrees to assign the policy to the financial institution (Assignee) for loan protection benefits.","Assignment benefits will be paid to Assignee up to outstanding loan amount; excess to nominee.","Submission of this form is adequate notice of assignment to the Company."],"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/1623-customer-declaration-and-assignment-form"}