{"id":2047,"title":"ACKO SECURE SHIELD PLUS PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/4_Proposal_Form_5_c6c8556d75.pdf","sha256":"252ee2ffadd9b3062213ca92071a9f95bd2132b88c26874b743bfdc5032a01c7","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for groups, associations, institutions, or corporate bodies to propose insurance coverage under the Acko Secure Shield Plus policy. It is completed by the proposer representing the group.","notes":["Complete the form in CAPITAL LETTERS.","Submit the original form only; copies will not be accepted.","Minor should not be declared as nominee.","All nominations will be in accordance with Section 39 of the Insurance Act 1938.","Use separate sheets if space is insufficient.","Pan No./TAN No. is mandatory for premium of INR 50,000 and above if accepted in Cash/Demand Draft, or INR 100,000 and above by Cheque/Credit Card/Debit Card.","The liability of the Company does not commence until full premium has been realized and acceptance communicated.","Prohibition of rebates as per Section 41 of Insurance Act, 1938 applies."],"title":"ACKO SECURE SHIELD PLUS PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"I. 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":"Enter the full name of the proposer group or entity","type":"text","label":"Proposer Name","options":[],"required":true,"pdf_field":""},{"help":"Briefly describe the business or nature 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 code of the correspondence address","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number of the principal contact person","type":"phone","label":"Telephone Number Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email address of the principal contact person","type":"email","label":"E-mail","options":[],"required":true,"pdf_field":""},{"help":"Enter identification number 1 if applicable","type":"text","label":"ID 1","options":[],"required":null,"pdf_field":""},{"help":"Enter identification number 2 if applicable","type":"text","label":"ID 2","options":[],"required":null,"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":true,"pdf_field":""},{"help":"Enter 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 nature","type":"choice","label":"Nature of Policy","options":["Names basis","Unnamed basis"],"required":true,"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":""},{"help":"Enter total number of insured persons","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":"Select Yes or No","type":"yes-no","label":"Are your employees/ Insured Persons at present insured under any similar product?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide insurer name if applicable","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Provide policy number if applicable","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Provide expiring terms of cover if applicable","type":"text","label":"Expiring terms of cover","options":[],"required":null,"pdf_field":""},{"help":"Provide period of insurance if applicable","type":"text","label":"Period of insurance","options":[],"required":null,"pdf_field":""},{"help":"Provide premium paid if applicable","type":"amount","label":"Premium paid","options":[],"required":null,"pdf_field":""},{"help":"Attach separate sheet with complete claim details","type":"attachment","label":"Claim details","options":[],"required":null,"pdf_field":""},{"help":"Provide incurred claims ratio if known","type":"text","label":"Incurred Claims Ratio","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"III. DETAILS OF INSURED PERSONS","fields":[{"help":"Enter the proposer name again","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Fill number of members/employees by category A, B, C","type":"table","label":"For unnamed members / Employees: Coverage Category / Sum Insured Level / Insured Category etc","options":[],"required":true,"pdf_field":""},{"help":"Attach Annexure 1 with named insured details","type":"attachment","label":"For Named member / Employees: Fill the Annexure 1","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"V. DECLARATION & AUTHORISATION","fields":[{"help":"Enter name of principal contact person signing the form","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":"Sign the form","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"VI. SALES PERSON/INSURANCE AGENT/INTERMEDIARY DECLARATION","fields":[{"help":"Enter full name of the agent or intermediary","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Enter license or ID number","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/intermediary"},{"title":"Annexure 1: Details of Named Insured Persons","fields":[{"help":"Fill columns: Sr No, Name of Insured Person, Unique Employee No/Customer Relationship number, Relationship of family with primary Insured, Date of Enrolment/Joining, Age, Gender, Nominee Name & Relationship with Insured Person, Mobile No. & Email ID, Coverage Category, Address of the Insured","type":"table","label":"Details of Insured Persons","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexure 2: Benefits Selection and Sum Insured","fields":[{"help":"Select the critical illness group opted for","type":"choice","label":"Critical Illness Group Opted","options":["15 CI’s","18 CI’s","25 CI’s","36 CI’s"],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group/Association/Institution/Corporate Body insurance proposals","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 provided 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 changes 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":4},"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/2047-acko-secure-shield-plus-proposal-form"}