{"id":2042,"title":"ACKO GROUP SINGLE SHIELD PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Proposal_Form_Acko_Group_Single_Shield_430ffcfbcd.pdf","sha256":"51dcf0f58aa6c572d0567c5248c16868679306786dcb616f06834a3b16a9cb78","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is for a Group/Association/Institution/Corporate Body to propose insurance coverage under the Acko Group Single Shield policy. It is filled by the proposer group or corporate body.","notes":["Complete the form in CAPITAL LETTERS.","Submit the original proposal form; copies will not be accepted.","Minimum age for membership is 18 years last birthday; maximum age for membership is 65 years last birthday; maximum age for maturity is 70 years last birthday.","Premium deposit is in advance.","Declaration of Good Health (DOGH) or long questionnaire is mandatory for all members for policy issuance.","Separate list should be attached for persons covered under each sum insured.","All nominations must comply with Section 39 of the Insurance Act 1938; minors cannot be nominees.","Refer to the policy document for servicing, grievance redressal, and TPA details.","Policyholders of the combi product may continue with either life or health insurance part separately during the policy term."],"title":"ACKO GROUP SINGLE SHIELD PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer (Group) Details","fields":[{"help":"Enter the start date of the proposed policy period in DD/MM/YYYY format","type":"date","label":"Proposed Policy Period From","options":[],"required":true,"pdf_field":""},{"help":"Full name of the proposing group or corporate body","type":"text","label":"Proposer Name","options":[],"required":true,"pdf_field":""},{"help":"Brief description of the business activity of the proposer","type":"text","label":"Description of the Proposer’s Business","options":[],"required":true,"pdf_field":""},{"help":"Name of the main contact person for correspondence","type":"text","label":"Principal Contact Person Name","options":[],"required":true,"pdf_field":""},{"help":"Full postal address for correspondence","type":"text","label":"Correspondence Address","options":[],"required":true,"pdf_field":""},{"help":"City of the correspondence address","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of the correspondence address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal PIN code of the correspondence address","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number of the principal contact","type":"phone","label":"Telephone Number Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email address of the principal contact","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Any identification number (e.g. GST, registration number)","type":"text","label":"ID 1","options":[],"required":false,"pdf_field":""},{"help":"Additional identification number if any","type":"text","label":"ID 2","options":[],"required":false,"pdf_field":""},{"help":"PAN or TAN number of the proposer","type":"text","label":"Pan No. / TAN No.","options":[],"required":true,"pdf_field":""},{"help":"GSTIN if applicable","type":"text","label":"Customer Goods & Service Tax Identification Number (if any)","options":[],"required":false,"pdf_field":""},{"help":"Specify mode of payment","type":"text","label":"Mode of Payment","options":[],"required":true,"pdf_field":""},{"help":"Select how often payments will be made","type":"choice","label":"Frequency of Payment","options":["Monthly","Quarterly","Half Yearly","Yearly"],"required":true,"pdf_field":""},{"help":"Select the nature of the group","type":"choice","label":"Nature of Group","options":["Employer/employee","Non-employer/employee"],"required":true,"pdf_field":""},{"help":"Describe the group members to be insured","type":"text","label":"Description of the Group to be insured","options":[],"required":true,"pdf_field":""},{"help":"Select the policy nature","type":"choice","label":"Nature of Policy","options":["Named basis","Unnamed basis"],"required":true,"pdf_field":""},{"help":"Specify type of travel (Air, Rail, Road, etc.) if applicable","type":"text","label":"Nature of Travel","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Please state whether all eligible Insured Persons/families of the Group / Association / Institution / Corporate Body are proposed for insurance?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer group or corporate body"},{"title":"Details of Previous Insurer(s) (If Renewal)","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Are your employees/ Insured Persons at present insured under any Group Health Insurance/Travel Insurance Policy?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of the previous insurer if applicable","type":"text","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Terms of expiring coverage","type":"text","label":"Expiring terms of cover","options":[],"required":false,"pdf_field":""},{"help":"Period covered by previous insurance","type":"text","label":"Period of insurance","options":[],"required":false,"pdf_field":""},{"help":"Premium amount paid under previous policy","type":"amount","label":"Premium paid","options":[],"required":false,"pdf_field":""},{"help":"Attach separate sheet with complete claim details","type":"attachment","label":"Claim details","options":[],"required":false,"pdf_field":""},{"help":"Provide incurred claims ratio if known","type":"number","label":"Incurred Claims Ratio","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer group or corporate body"},{"title":"Benefits","fields":[{"help":"Select the life cover option","type":"choice","label":"Life Cover Option (Main Benefit)","options":["Death Benefit (Level Cover)","Death Benefit (Decreasing Cover)"],"required":true,"pdf_field":""},{"help":"Specify the life option plan - Death benefit","type":"text","label":"Plan","options":[],"required":true,"pdf_field":""},{"help":"Specify category of insured persons","type":"text","label":"Category","options":[],"required":true,"pdf_field":""},{"help":"Select basis of coverage","type":"choice","label":"Basis of Coverage (Individual/Floater)","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Specify number of floater units if applicable","type":"number","label":"Floater Unit (in case of Floater)","options":[],"required":false,"pdf_field":""},{"help":"Refer Annexure 2 for benefits selected","type":"attachment","label":"Selected Benefits Base and Optional","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer group or corporate body"},{"title":"Declaration & Authorisation","fields":[{"help":"Name of the person signing the declaration","type":"text","label":"Principle Contact Person Name","options":[],"required":true,"pdf_field":""},{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of the proposer or authorized signatory","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"principal contact person of proposer"},{"title":"Sales Person/Insurance Agent/Intermediary Declaration","fields":[{"help":"Full name of the agent or intermediary","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"License or ID number of the intermediary","type":"text","label":"License No. / ID (Agent / Corporate Agent / Broker / Sales Person)","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of proposer or intermediary","type":"signature","label":"Signature of Proposer/ Intermediary","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insurance agent or intermediary"}],"deadlines":[],"applies_to":"Group insurance proposals for combined life and health insurance benefits under the Acko Group Single Shield policy","attachments":["Separate sheet with complete claim details (if applicable)","Annexure 1: List of Insured Persons","Annexure 2: Benefits selection and details"],"declarations":["The proposer declares that all information provided is true, accurate, and complete to the best of their knowledge.","The policy will come into force only after full payment of premium and acceptance by the company.","The proposer will notify any changes in travel mode, occupation, or health after submission but before acceptance.","The proposer consents to the company seeking travel, medical, and insurance information for underwriting and claims.","The company may share proposal and claim information with governmental or regulatory authorities.","If information is found untrue, the company may alter or cancel coverage.","The insurance agent/intermediary declares that the proposal form contents and implications have been explained to the proposer.","The agent/intermediary acknowledges that untrue statements or non-disclosure may lead to policy variation or cancellation."],"dropped_labels":6},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"1800-210-1992","label":"Customer Care Number","level":null,"hours":"Monday to Sunday: 9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/contact-us/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nLife Insurance\n/\nAcko Life Insurance Customer Care | Customer Care","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"+91 8069067215","label":"Customer Care Phone Number for PERSONS WITH DISABILITIES (PwD)","level":null,"hours":"Monday to Sunday: 9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/contact-us/","quote":"y to Sunday: 9:00 AM – 8:00 PM\nACKO Life Insurance Customer Care Phone Number for PERSONS WITH DISABILITIES (PwD)\nCall: +91 8069067215\nMonday to Sunday: 9:00 AM – 8:00 PM\nProducts\nLife insurance\nTerm insurance\n1 crore term insurance\nCompany\nAbout us\nCare","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-210-1992","label":"Grievance desk phone number","level":1,"hours":null,"applies_to":"life","source_url":"https://www.acko.com/life/customer-service/grievance-redressal/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Customer Service\n/\nACKO Life Insurance Grievan","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Ms. Komal Arawat (Grievance Redressal Officer) Acko Life Insurance Limited, 36/5 Hustlehub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Bangalore – 560102","label":"Grievance Redressal Officer postal address","level":2,"hours":null,"applies_to":"life","source_url":"https://www.acko.com/life/customer-service/grievance-redressal/","quote":null,"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/acko-life-insurance/2042-acko-group-single-shield-proposal-form"}