{"id":2046,"title":"SECURE SHIELD PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/4_Proposal_Form_1_73ae316c01.pdf","sha256":"e89f3f53d60cad6843542ae8e54aff3332efa263952b5e53c48ade0782c401af","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for groups, associations, institutions, or corporate bodies to propose insurance coverage under the Secure Shield policy. It is filled by the proposer representing the group.","notes":["Complete the form in CAPITAL LETTERS.","Submit the original form; copies will not be accepted.","Pan No./TAN No. is mandatory for premium of INR 50,000+ in cash/DD or INR 100,000+ by cheque/credit/debit card.","Minor should not be declared as nominee.","All nominations will be in accordance with Section 39 of the Insurance Act 1938.","The liability of the company does not commence until full premium is received and proposal accepted.","Use separate sheets if space is insufficient.","Prohibition of rebates applies as per Section 41 of Insurance Act 1938."],"title":"SECURE SHIELD PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"I. PROPOSER (GROUP) DETAILS","fields":[{"help":"Enter start date of policy period in DD/MM/YYYY format","type":"date","label":"Proposed Policy Period From","options":[],"required":true,"pdf_field":""},{"help":"Name of the group or organization proposing insurance","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 correspondence address","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of correspondence address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal code of correspondence address","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number of principal contact","type":"phone","label":"Telephone Number Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email address of principal contact","type":"email","label":"E-mail","options":[],"required":true,"pdf_field":""},{"help":"Identification number 1 if applicable","type":"text","label":"ID 1","options":[],"required":false,"pdf_field":""},{"help":"Identification number 2 if applicable","type":"text","label":"ID 2","options":[],"required":false,"pdf_field":""},{"help":"Mandatory if premium is INR 50,000+ in cash/DD or INR 100,000+ by cheque/credit/debit card","type":"text","label":"Pan No. / TAN No.","options":[],"required":null,"pdf_field":""},{"help":"GSTIN if applicable","type":"text","label":"Customer Goods & Service Tax Identification Number (if any)","options":[],"required":false,"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":"Select the policy type","type":"choice","label":"Nature of Policy","options":["Names basis","Unnamed basis"],"required":true,"pdf_field":""},{"help":"Indicate if all eligible persons are proposed for insurance","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":""},{"help":"Total count of insured persons including dependents","type":"number","label":"Please state the total number of Insured Persons to be covered (including families / dependents wherever covered)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"II. DETAILS OF PREVIOUS INSURER(S) (IF RENEWAL)","fields":[{"help":"Indicate if currently insured under similar product","type":"yes-no","label":"Are your employees/ Insured Persons at present insured under any similar product?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of 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 for 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":"Claims ratio of previous policy","type":"text","label":"Claims Ratio","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"III. DETAILS OF INSURED PERSONS","fields":[{"help":"Name of the proposer group","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter number of members/employees by category for unnamed members","type":"table","label":"For unnamed members / Employees: Coverage Category / Sum Insured Level / Insured Category etc No of Members / Employees Category A Category B Category C","options":[],"required":true,"pdf_field":""},{"help":"Attach Annexure 1 with details of named insured persons","type":"attachment","label":"For Named member / Employees: Fill the Annexure 1","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"V. DECLARATION & AUTHORISATION","fields":[{"help":"Name of the principal contact 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 authorized proposer","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":"proposer"},{"title":"VI. SALES PERSON/INSURANCE AGENT/INTERMEDIARY DECLARATION","fields":[{"help":"Name of the insurance 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 the declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of the 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/intermediary"}],"deadlines":[],"applies_to":"Group insurance proposals for Secure Shield policy","attachments":["Separate sheet with complete claim details (if applicable)","Annexure 1: Details of Named Insured Persons","Annexure 2: Benefits Selection and Sum Insured"],"declarations":["The proposer declares that all information given is true 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 change in occupation or health after submission but before acceptance.","The proposer consents to the company seeking 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."],"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/2046-secure-shield-proposal-form"}