{"id":1986,"title":"HEALTH INSURANCE ENDORSEMENT FORM","purpose":"service","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/20190531001-endorsement--form.pdf","sha256":"b0952d3251257837a26fbff77e1e334089dfd9f9be1af899e9637d12642ea218","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders to request endorsements such as addition or deletion of members, changes in plan or sum insured, changes in proposer or nominee details, and contact information updates for their health insurance policy.","notes":["Medical underwriting is required for added members.","Fresh waiting period applies to enhanced limits from effective date of enhancement.","Medical test required for adults for sum insured above 10 lacs if existing sum insured is up to 10 lacs.","Cost of medical check-up for policy issuance will be paid by company; if proposal declined, medical cost will be deducted from premium.","Name and Date of Birth cannot be changed at the same time.","Please fill all particulars in CAPITAL letters only."],"title":"HEALTH INSURANCE ENDORSEMENT FORM","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Plan and Policy Details","fields":[{"help":"","type":"choice","label":"Plan Type","options":["Individual","Floater"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Plan","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Options","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Tenure","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Plan Details","options":[],"required":null,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Sub - limit (If Applicable)","options":[],"required":false,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Add-ons Cover (If Applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Sum Insured","options":["1A + 2C","2A + 3C","1A + 1C","2A + 2C","1A 1C","2A 2A+ 1C"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Existing Product","options":["ICICI Lombard Complete Health Insurance","Health Booster"],"required":null,"pdf_field":""},{"help":"Provide your existing policy number","type":"text","label":"Existing Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Select No or provide details if applicable","type":"text","label":"Deductible (If Applicable)","options":["No","If Not, please provide details:"],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Addition/Deletion of Members","fields":[{"help":"Select whether adding or deleting members","type":"choice","label":"Type (Add/Del)","options":["Add","Del"],"required":null,"pdf_field":""},{"help":"Enter full name of member","type":"text","label":"Full Name (First, Middle, Last)","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (M/F/Third Gender)","options":["M","F","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YY format","type":"date","label":"Date of Birth (DD/MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Enter height in feet and inches","type":"text","label":"Height (feet / inch)","options":[],"required":false,"pdf_field":""},{"help":"Enter weight in kilograms","type":"number","label":"Weight (kgs)","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN number if available","type":"text","label":"PAN No.","options":[],"required":false,"pdf_field":""},{"help":"Confirm if all insured are Indian nationals and residents","type":"yes-no","label":"Are all insured Indian nationals and Indian residents?","options":["Yes"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Members Details","fields":[{"help":"Enter insured member number","type":"number","label":"Insured No.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Full Name (First, Middle, Last)","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (M/F/Third Gender)","options":["M","F","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth (DD/MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Contact Details","fields":[{"help":"Enter full correspondence address","type":"text","label":"Correspondence Address","options":[],"required":null,"pdf_field":""},{"help":"Enter landmark near address","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter landline number including STD code","type":"phone","label":"Landline Number (with STD Code)","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile Number*","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail address","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Name/Place/DOB/DOJ","fields":[{"help":"Enter new Date of Joining if applicable","type":"date","label":"New DOJ (If applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Note: Name and Date of Birth can not be changed at a time.","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Nominee Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of Nominee","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship with nominee","type":"text","label":"Relationship","options":[],"required":null,"pdf_field":""},{"help":"Enter name of appointee if applicable","type":"text","label":"Name of Appointee","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth of appointee if applicable","type":"date","label":"Date of Birth (If Applicable)","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship of appointee","type":"text","label":"Relationship of Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Changes in Proposer Details","fields":[{"help":"Fill all parts of name in CAPITAL letters","type":"text","label":"Proposer’s Name (please leave a space after each part of name)","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Mr. / Ms. / Dr.","options":["Mr.","Ms.","Dr."],"required":null,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married"],"required":null,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Salaried","Self Employed","Professional","Others"],"required":null,"pdf_field":""},{"help":"Provide details if occupation is Others","type":"text","label":"Details","options":[],"required":false,"pdf_field":""},{"help":"Select nationality and specify if Others","type":"choice","label":"Nationality","options":["Indian","Others (please specify)"],"required":null,"pdf_field":""},{"help":"Select highest qualification","type":"choice","label":"Educational Qualifications","options":["Lesser than matriculation","Matriculation","Graduate","Post-graduate","Professional Course"],"required":null,"pdf_field":""},{"help":"Select annual income range","type":"choice","label":"Annual Income","options":["Less than 5 Lacs","Between 5 - 10 Lacs","Between 10 - 20 Lacs","20 Lacs and above"],"required":null,"pdf_field":""},{"help":"Provide GST number if applicable","type":"text","label":"GST Number (If Applicable)","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN card number","type":"text","label":"PAN Card No.","options":[],"required":false,"pdf_field":""},{"help":"Provide passport number","type":"text","label":"Passport No.","options":[],"required":false,"pdf_field":""},{"help":"Provide Aadhaar number","type":"text","label":"Adhar No.","options":[],"required":false,"pdf_field":""},{"help":"Select residential status","type":"choice","label":"Residential Status","options":["Indian Resident","Non Resident Indian"],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile Number*","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"ICICI Lombard Complete Health Insurance and Health Booster plans","attachments":["Documents supporting health declaration if treatment was received"],"declarations":["Only selected changes will be endorsed in new policy.","Changes in proposer details, deletion of member and changes in plan/Sum Insured can be done at the time of renewal only.","Premium may change on the basis of type of endorsement.","Any discrepancy or non-disclosure of medical facts recorded in this document which is evident at the time of claims will be deemed to be non disclosure/misrepresentation of material facts leading to policy cancellation and making the claim liable for rejection.","I declare that I or anyone insured has not consulted or received treatment or had no health changes since policy inception, or I declare that treatment was received or health condition changed and provide supporting documents."],"dropped_labels":2},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/icici-lombard-general-insurance/1986-health-insurance-endorsement-form"}