{"id":1905,"title":"Proforma Service Request Form","purpose":"service","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/PROFORMA_Website_d1ef30297f.pdf","sha256":"dd79c4f20ad59d7ccf5c42f575c7f7ceb31b476ca0df6e3ea36af1f833fa536c","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder (proposer) to request changes or corrections to their insurance policy details such as address, occupation, contact details, or insured details.","notes":["* Please fill mandatory fields"],"title":"Proforma Service Request Form","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Service Request Details","fields":[{"help":"Enter your policy number as printed on your policy document.","type":"text","label":"Policy Number*","options":[],"required":true,"pdf_field":""},{"help":"Tick all applicable changes you want to request.","type":"checkbox","label":"I request you to kindly effect the following change(s) in the policy","options":["Change of address","Change of Occupation","Change of Contact details","Correction in Insured details","Others"],"required":null,"pdf_field":""},{"help":"Fill only if requesting change of address.","type":"text","label":"Change of address :","options":[],"required":false,"pdf_field":""},{"help":"Enter the new address.","type":"text","label":"New Address          :","options":[],"required":false,"pdf_field":""},{"help":"Enter the city of the new address.","type":"text","label":"City :","options":[],"required":false,"pdf_field":""},{"help":"Enter the postal pin code.","type":"number","label":"Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"Enter the state of the new address.","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"Enter the country of the new address.","type":"text","label":"Country :","options":[],"required":false,"pdf_field":""},{"help":"Enter your email address.","type":"email","label":"Email id :","options":[],"required":false,"pdf_field":""},{"help":"Enter your contact phone number.","type":"phone","label":"Contact No. :","options":[],"required":false,"pdf_field":""},{"help":"Enter your date of birth.","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter your gender.","type":"text","label":"Gender","options":[],"required":false,"pdf_field":""},{"help":"Sign here to authorize the request.","type":"signature","label":"Signature of proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter the branch name where the form is submitted.","type":"text","label":"Branch Name :","options":[],"required":false,"pdf_field":""},{"help":"Enter the full name of the proposer.","type":"text","label":"Proposer Name*","options":[],"required":true,"pdf_field":""},{"help":"Fill only if requesting change of contact details.","type":"text","label":"Change of contact details :","options":[],"required":false,"pdf_field":""},{"help":"Fill only if requesting change of occupation.","type":"text","label":"Change in Occupation :","options":[],"required":false,"pdf_field":""},{"help":"Fill only if requesting correction in insured details.","type":"text","label":"Correction in Insured Details :","options":[],"required":false,"pdf_field":""},{"help":"Enter the name of the insured person if different from proposer.","type":"text","label":"Name of the Insured person","options":[],"required":false,"pdf_field":""},{"help":"Specify any other service request not listed above.","type":"text","label":"Others (Please specify any other Requirement):","options":[],"required":false,"pdf_field":""},{"help":"You must agree to this declaration to submit the form.","type":"checkbox","label":"Declaration :","options":["I hereby declare that the information provided above are true to the best of my knowledge."],"required":null,"pdf_field":""},{"help":"Enter the date of signing the form.","type":"date","label":"Date :","options":[],"required":false,"pdf_field":""},{"help":"Enter the place where the form is signed.","type":"text","label":"Place :","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder (proposer)"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["I hereby declare that the information provided above are true to the best of my knowledge."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"044-69006900","label":"24 hours help-line","level":null,"hours":"24 hours","applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 425 2255","label":"Toll Free No.","level":null,"hours":"24 hours","applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be submitted while filing a reimbu","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"4th Floor, Balaji Complex, No.15, Whites Lane, Whites Road, Royapettah, Chennai-600014","label":"Grievance Redressal Officer postal address","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"tarhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, Balaji Complex, No.15, Whites Lane, Whites Road, Royapettah, Chennai-600014 lnsured person may also approach the grievance cell at any of the Company’s branches with the details of grievance. If","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@starhealth.in","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"e: In case of any grievance the Insured Person may contact the Company through\nWebsite | : www.starhealth.in\nE-mail | : gro@starhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, B","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"grievances@starhealth.in","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"rievance the Insured Person may contact the Company through\nWebsite | : www.starhealth.in\nE-mail | : gro@starhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, Balaji Complex, No.15, Whit","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044-69006900","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044-43664600","label":"Grievance Officer","level":2,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"d with the redressal of grievance through one of the above methods, Insured Person may contact the grievance officer at 044-43664600.","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.starhealth.in/grievance-redressal","label":"Updated details of grievance officer","level":null,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Policy_Star_Health_Assure_Insurance_Policy_V_9_c53663e68a.pdf","quote":"rson may contact the grievance officer at 044-43664600. For updated details of grievance officer, kindly refer the link https://www.starhealth.in/grievance-redressal If Insured Person is not satisfied with the redressal of grievance through above methods, the Insured Person may also a","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/star-health-and-allied-insurance/1905-proforma-service-request-form"}