{"id":1897,"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/SuperTopUp-ChangeRequestForm/61e865d8-c0c6-b4ab-c8fa-186833b3c9b2?t=28","sha256":"a66042212577d24b218027b90728df5bd155c4f3e176deaaad566525b311850c","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by policyholders or insured persons to request changes to their 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 persons.","Any alteration in the form must be counter signed by the policyholder.","Any change requested in address, name, date of birth, or contact details will be incorporated for all your policies with the insurer.","Women changing name post marriage must submit a copy of the Marriage Certificate.","Significant name changes require a gazetted notification.","Minor name corrections require valid government proof such as Driving License, PAN Card, Election Card, Passport, Aadhaar Card, or other valid proof.","Change in zone may affect premium calculation based on the city zone.","Policy terms and premiums may be modified if there is a material change in information provided at proposal."],"title":"CHANGE REQUEST FORM","submit":{"to":"ManipalCigna Health Insurance Company Limited","how":"","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 old name","type":"text","label":"From","options":[],"required":true,"pdf_field":""},{"help":"Enter new name","type":"text","label":"To","options":[],"required":true,"pdf_field":""},{"help":"Select document submitted as proof of name change","type":"choice","label":"Document Submitted","options":["Gazetted Notification","Driving License","PAN","Election Card","Aadhaar Card","Others (Please Specify)"],"required":true,"pdf_field":""}],"filled_by":"policyholder or insured"},{"title":"Change in Date of Birth","fields":[{"help":"Enter old date of birth","type":"date","label":"From","options":[],"required":true,"pdf_field":""},{"help":"Enter new date of birth","type":"date","label":"To","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for date of birth change","type":"text","label":"Reason for Change:","options":[],"required":true,"pdf_field":""},{"help":"Select 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 to ProHealth Insurance and ProHealth Select)","fields":[{"help":"Enter full name","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter current city","type":"text","label":"Current Zone: City:","options":[],"required":null,"pdf_field":""},{"help":"Enter current pin code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter current state","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter current zone","type":"text","label":"Zone:","options":[],"required":null,"pdf_field":""},{"help":"Enter new city","type":"text","label":"New Zone: City:","options":[],"required":null,"pdf_field":""},{"help":"Enter new pin code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter new state","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter new zone","type":"text","label":"Zone:","options":[],"required":null,"pdf_field":""},{"help":"Explain 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 nominee's full name","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship 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":"phone","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","type":"table","label":"Sr. No, Name (First*, Middle, Last*), Gender* (Male/ Female/ Other), DOB* (DD/MM/YYYY), Relationship with Proposer*, Claim Details Yes/No, Claim No (If Yes), Claim Status (If Yes) Yes/No, Yes/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":["Covert all eligible Healthy Rewards","Convert only specific Healthy Rewards. Specify Points __________"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Health Condition","fields":[{"help":"Enter name of insured person","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter illness or disease details","type":"text","label":"Name of Illness / Diseases suffering from or suffered in the past","options":[],"required":null,"pdf_field":""},{"help":"Enter date of first diagnosis","type":"date","label":"Date of first diagnosis:","options":[],"required":null,"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 old 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":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness:","options":[],"required":null,"pdf_field":""},{"help":"Enter place of witness signature","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""}],"filled_by":"witness"},{"title":"Customer Acknowledgement Slip","fields":[{"help":"Filled by insurance executive","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Filled by insurance executive","type":"text","label":"Type of Request Received:","options":[],"required":null,"pdf_field":""},{"help":"Filled by insurance executive","type":"text","label":"Received By (ManipalCigna Health Insurance Executive):","options":[],"required":null,"pdf_field":""},{"help":"Filled by insurance executive","type":"date","label":"Date of Receipt:","options":[],"required":null,"pdf_field":""}],"filled_by":"office use"}],"deadlines":[],"applies_to":"Super Top Up and other health insurance policies with ManipalCigna Health Insurance Company Limited","attachments":["Proof of address document (Passport, Driving License, Leave and License Agreement, Bank Statement, Others)","Proof of name change document (Gazetted Notification, Driving License, PAN, Election Card, Aadhaar Card, Others)","Proof of date of birth change document (PAN, Passport, Driving License, Others)","Marriage Certificate (for name change post marriage for women)"],"declarations":["The policyholder confirms having read and understood all policy terms and conditions including those applicable to this request.","The policyholder understands and accepts that the request shall be processed according to the policy terms and conditions.","If the policyholder signs in vernacular or affixes thumb impression, a witness declares having explained the form contents and policy terms in a language understood by the policyholder."],"dropped_labels":1},"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/1897-change-request-form"}