{"id":1869,"title":"CHANGE REQUEST FORM","purpose":"service","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.manipalcigna.com/documents/20124/0/ArogyaSanjeevani-ChangeRequestForm/a8c9c8e4-6d24-5c47-be35-c82f7b0adad7?t=28","sha256":"10cf8ff810712912ebd495b18ee58c86f04dcf958888ee2dc576f993b78f2fe7","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by policyholders or insured persons to request changes to their Arogya Sanjeevani health insurance policy details such as occupation, address, name, date of birth, zone, nominee, contact details, health condition, or other information.","notes":["Fill the form in BLOCK LETTERS.","All details marked * are mandatory.","Put a (9) mark wherever applicable.","Use a separate form for changes in more than one policy or single policy with multiple insured.","Any alteration in form needs to be counter signed by the policy holder.","Any change requested in address, name, date of birth will be incorporated for all your policies with the insurer.","Women changing name post marriage must submit Marriage Certificate.","Sign or affix thumb impression in the presence of a witness if signing in vernacular or thumb impression.","Current zone is based on city in correspondence address; change in city may affect premium.","Original or valid documents must be submitted as proof for changes.","Policy terms and premium may be modified if there is a material change in information."],"title":"CHANGE REQUEST FORM","submit":{"to":"ManipalCigna Health Insurance Company Limited","how":"post / e-mail / in person","address":"Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063; E-mail: customercare@manipalcigna.com"},"purpose":"service","sections":[{"title":"Policy Details","fields":[{"help":"Enter the name of the insurance product","type":"text","label":"Name of Product :","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of filling the form","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter the full name of the policyholder in block letters","type":"text","label":"Policy Holder Name:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Change in Occupation (For Insured Only)","fields":[{"help":"Enter the full name of the insured person","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter the occupation as originally declared","type":"text","label":"Occupation as declared in the Policy:","options":[],"required":true,"pdf_field":""},{"help":"Enter the current occupation","type":"text","label":"Current Occupation:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Change in Address (For Policy Holder Only)","fields":[{"help":"Enter your permanent address","type":"text","label":"Permanent Address*:","options":[],"required":true,"pdf_field":""},{"help":"Enter city of permanent address","type":"text","label":"City*:","options":[],"required":true,"pdf_field":""},{"help":"Enter town or district of permanent address","type":"text","label":"Town (District):","options":[],"required":false,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"State*:","options":[],"required":true,"pdf_field":""},{"help":"Enter pin code of permanent address","type":"number","label":"Pin Code*:","options":[],"required":true,"pdf_field":""},{"help":"Select the document submitted as proof of address","type":"choice","label":"Document Submitted:","options":["Passport","Driving License","Leave and License Agreement","Bank Statement","Others (Please Specify)"],"required":true,"pdf_field":""},{"help":"Enter your correspondence address","type":"text","label":"Correspondence Address*:","options":[],"required":true,"pdf_field":""},{"help":"Enter city of correspondence address","type":"text","label":"City*:","options":[],"required":true,"pdf_field":""},{"help":"Enter town or district of correspondence address","type":"text","label":"Town (District):","options":[],"required":false,"pdf_field":""},{"help":"Enter state of correspondence address","type":"text","label":"State*:","options":[],"required":true,"pdf_field":""},{"help":"Enter pin code of correspondence address","type":"number","label":"Pin Code*:","options":[],"required":true,"pdf_field":""},{"help":"Select the document submitted as proof of correspondence address","type":"choice","label":"Document Submitted:","options":["Passport","Driving License","Leave and License Agreement","Bank Statement","Others (Please Specify)"],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Change in Name","fields":[{"help":"Enter the full name for which change is requested","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Read the note about name change","type":"text","label":"Note: Any change requested in Name will be incorporated for all your policies with us","options":[],"required":null,"pdf_field":""},{"help":"Enter the current name","type":"text","label":"From","options":[],"required":true,"pdf_field":""},{"help":"Enter the new name","type":"text","label":"To","options":[],"required":true,"pdf_field":""},{"help":"Select the document submitted as proof of name change","type":"choice","label":"Document Submitted","options":["Gazetted Notification","Driving License","PAN","Election Card","Aadhar Card","Others (Please Specify)"],"required":true,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Change in Date of Birth","fields":[{"help":"Enter the current date of birth","type":"date","label":"From","options":[],"required":true,"pdf_field":""},{"help":"Enter the new date of birth","type":"date","label":"To","options":[],"required":true,"pdf_field":""},{"help":"Provide reason for date of birth change","type":"text","label":"Reason for Change:","options":[],"required":true,"pdf_field":""},{"help":"Select the document submitted as proof of date of birth change","type":"choice","label":"Document Submitted:","options":["PAN","Passport","Driving License","Others (Please Specify)"],"required":true,"pdf_field":""},{"help":"Indicate if any claim has been settled","type":"yes-no","label":"Claim Settled (If Any):","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if any claim is pending","type":"yes-no","label":"Claim Pending (If Any):","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Change in Zone (Applicable only to ProHealth Insurance)","fields":[{"help":"Enter the name of the policyholder or insured","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter current city of zone","type":"text","label":"Current Zone: City:","options":[],"required":true,"pdf_field":""},{"help":"Enter pin code of current zone","type":"number","label":"Pin Code:","options":[],"required":true,"pdf_field":""},{"help":"Enter state of current zone","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Enter current zone","type":"text","label":"Zone:","options":[],"required":true,"pdf_field":""},{"help":"Enter new city of zone","type":"text","label":"New Zone: City:","options":[],"required":true,"pdf_field":""},{"help":"Enter pin code of new zone","type":"number","label":"Pin Code:","options":[],"required":true,"pdf_field":""},{"help":"Enter state of new zone","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Enter new zone","type":"text","label":"Zone:","options":[],"required":true,"pdf_field":""},{"help":"Provide reason for zone change","type":"text","label":"Reason for Change in Zone:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Change of Nominee","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee with policyholder","type":"text","label":"Relationship with Policy Holder:","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Change in Contact Details (For Policy Holder Only)","fields":[{"help":"Enter residence phone number","type":"text","label":"Residence:","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile:","options":[],"required":false,"pdf_field":""},{"help":"Enter primary email address","type":"email","label":"E Mail ID 1:","options":[],"required":false,"pdf_field":""},{"help":"Enter secondary email address","type":"email","label":"E Mail ID 2:","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Member Deletion","fields":[{"help":"Fill details of members to be deleted: Name (First, Middle, Last), Gender, DOB (DD/MM/YYYY), Relationship with Proposer, Claim Details (Yes/No), Claim No (if Yes), Claim Status (if Yes)","type":"table","label":"Sr. No","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Healthy Rewards Redemption (Applicable only to ProHealth Insurance and ProHealth Select (A))","fields":[{"help":"Select option for Healthy Rewards conversion","type":"choice","label":"I would like to convert my balance Healthy Rewards to Health Maintenance Benefit with effect from the date of this application.","options":["Convert all eligible Healthy Rewards","Convert only specific Healthy Rewards. Specify Points __________"],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Health Condition","fields":[{"help":"Enter name of insured whose health condition is changing","type":"text","label":"Name of Insured","options":[],"required":false,"pdf_field":""},{"help":"Enter illness or disease details","type":"text","label":"Name of Illness / Diseases suffering from or suffered in the past","options":[],"required":false,"pdf_field":""},{"help":"Enter date of first diagnosis","type":"date","label":"Date of first diagnosis:","options":[],"required":false,"pdf_field":""},{"help":"Provide additional health details","type":"text","label":"Any other details (if operated/hospitalised/undergoing treatment/medication):","options":[],"required":false,"pdf_field":""},{"help":"Explain reason for health condition change","type":"text","label":"Reason for Change / Addition:","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Any Other Change That You Wish to Inform Us","fields":[{"help":"Enter full name","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter previous information","type":"text","label":"Change From:","options":[],"required":true,"pdf_field":""},{"help":"Enter new information","type":"text","label":"Change To:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Policy Holder Declaration","fields":[{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign or affix thumb impression","type":"signature","label":"Signature /Thumb impression of Policy Holder:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Witness Declaration (If policyholder signed in vernacular or thumb impression)","fields":[{"help":"Enter date of witness signature","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of witness signature","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Arogya Sanjeevani Policy, ManipalCigna","attachments":["Proof of address document (Passport, Driving License, Leave and License Agreement, Bank Statement, Others)","Proof of name change document (Marriage Certificate, Gazetted Notification, Driving License, PAN Card, Election Card, Passport, Aadhar Card, Other valid government proof)","Proof of date of birth change document (PAN, Passport, Driving License, Others)"],"declarations":["I hereby confirm having read and understood all the policy terms and conditions including those applicable to this request.","I understand and accept that my request shall be processed in accordance with the terms and conditions of the policy.","If the policyholder signs in vernacular or affixes thumb impression, a witness must declare that the contents were explained and understood."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"support@galaxyhealth.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/contact-us","quote":"0 203 0007\nRegistered Office\nPrestige Polygon, 12th Top Floor (P),\n#471, Anna Salai, Nandanam,\nChennai - 600 035.\nEmail\nsupport@galaxyhealth.com\nFollow us\nNeed Assistance? Get in Touch with the Right Team!\nAt\nGalaxy Health\n, we strive for\nquick response times\n,\nex","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 203 0007","label":"Customer Care Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/contact-us","quote":"Contact Us | GalaxyHealth.com\nToll Free Number: 1800 203 0007\nProducts\nHealth Insurance\nGalaxy Marvel\nGalaxy Promise\nGalaxy Twin 360\nArogya Sanjeevani Policy, Galaxy Health Insuranc","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Prestige Polygon, 12th Top Floor (P), # 471, Anna Salai, Nandanam, Chennai – 600035.","label":"Grievance Redressal Officer Corporate Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/grievance-redressal","quote":"r Grievance Redressal Officer at Corporate Office.\nMs.G.Veni\nGrievance Redressal Officer\nCorporate Grievance Department\nPrestige Polygon, 12th Top Floor (P),\n# 471, Anna Salai,\nNandanam, Chennai – 600035.\nEmail ID: gro@galaxyhealth.com\nContact No: 044-40017238.\nToll free number: 1800-203-0007 and press 3.\nOr\nYou may also","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@galaxyhealth.com","label":"Grievance Redressal Officer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/grievance-redressal","quote":"e Grievance Department\nPrestige Polygon, 12th Top Floor (P),\n# 471, Anna Salai,\nNandanam, Chennai – 600035.\nEmail ID: gro@galaxyhealth.com\nContact No: 044-40017238.\nToll free number: 1800-203-0007 and press 3.\nOr\nYou may also lodge a complaint through the po","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 203 0007","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/grievance-redressal","quote":"Grievance Redressal | We are Here to Help You | GalaxyHealth.com\nToll Free Number: 1800 203 0007\nProducts\nHealth Insurance\nGalaxy Marvel\nGalaxy Promise\nGalaxy Twin 360\nArogya Sanjeevani Policy, Galaxy Health Insuranc","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044-40017238","label":"Grievance Redressal Officer Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/grievance-redressal","quote":"olygon, 12th Top Floor (P),\n# 471, Anna Salai,\nNandanam, Chennai – 600035.\nEmail ID: gro@galaxyhealth.com\nContact No: 044-40017238.\nToll free number: 1800-203-0007 and press 3.\nOr\nYou may also lodge a complaint through the portals mentioned below.\nâ€","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-203-0007 and press 3","label":"Grievance Toll free number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/grievance-redressal","quote":"1, Anna Salai,\nNandanam, Chennai – 600035.\nEmail ID: gro@galaxyhealth.com\nContact No: 044-40017238.\nToll free number: 1800-203-0007 and press 3.\nOr\nYou may also lodge a complaint through the portals mentioned below.\n•    Bima Bharosa portal of IRDAI through the","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044 - 4001 7238","label":"Grievance Redressal Officer Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/assets/preloaded/Galaxy_Companion_Rider_CIS_Sep_2026_V2.pdf","quote":"alaxyhealth.com Toll free : 18002030007 Senior Citizens may call at 18002030007 E-mail : gro@galaxyhealth.com Ph. No. : 044 - 4001 7238 Courier : Prestige Polygon – 12th Top Floor (P), No. 471, Anna Salai, Nandanam, Chennai – 600035. lnsured person may al","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"18002030007","label":"Toll Free Number for Grievance","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/assets/preloaded/Galaxy_Companion_Rider_CIS_Sep_2026_V2.pdf","quote":"available on the digital platform. b. Call the 24-hour helpline for assistance 0804736248. Senior Citizens may call at 18002030007. c. Produce the ID Card issued by the Company at the Network Facility Helpdesk. Note: The company reserves the right to","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/galaxy-health-insurance/1869-change-request-form"}