{"id":2080,"title":"Proposal Form for Aviva Sampoorna Suraksha","purpose":"proposal","insurer":{"slug":"aviva-life-insurance","name":"Aviva Life Insurance Company India Limited"},"source_pdf":"https://www.avivaindia.com/sites/default/files/SS%20Tamil.pdf","sha256":"0aef7fa3a4c6db8973aa6249786620d0c43429e78a69ecab615a3067c9404408","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Aviva Sampoorna Suraksha life insurance policy. The proposer fills it to provide personal, policy, health, and nomination details for underwriting and policy issuance.","notes":["Fill the form in CAPITAL LETTERS.","Proof of age is mandatory.","Initial payment must accompany the proposal form.","Refunds for cash deposits will be made by cheque only.","Use the vernacular declaration box to write the declaration in your mother tongue if applicable.","If signature is in vernacular or thumb impression, the declaration must be made by a credible person unconnected with Aviva Life Insurance.","Section 41 and 45 of Insurance Act 1938 apply regarding rebates and policy contestability."],"title":"Proposal Form for Aviva Sampoorna Suraksha","submit":{"to":"Branch Office or any other manner as approved by the Company","how":"post or in person","address":""},"purpose":"proposal","sections":[{"title":"Proposal Deposit Details","fields":[{"help":"Enter cheque or demand draft number if payment is made by these methods","type":"text","label":"Cheque/DD No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount paid as initial payment","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"If you are an existing customer, enter your customer ID","type":"text","label":"Customer ID (for existing customer)","options":[],"required":false,"pdf_field":""},{"help":"Enter voucher number if applicable","type":"text","label":"Voucher Number","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of bank or branch on which cheque/DD is drawn","type":"text","label":"Drawn on","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or adviser"},{"title":"Life to be Insured Details","fields":[{"help":"Select appropriate title","type":"choice","label":"Mr/Mrs/Miss/Ms","options":["Mr","Mrs","Miss","Ms"],"required":true,"pdf_field":""},{"help":"Enter first and middle names in capital letters","type":"text","label":"Forenames","options":[],"required":true,"pdf_field":""},{"help":"Enter father's or husband's name","type":"text","label":"Father's/Husband's Name","options":[],"required":true,"pdf_field":""},{"help":"Enter current mailing address","type":"text","label":"Mailing Address","options":[],"required":true,"pdf_field":""},{"help":"Enter village name if applicable","type":"text","label":"Village","options":[],"required":false,"pdf_field":""},{"help":"Enter post office name","type":"text","label":"P.O.","options":[],"required":false,"pdf_field":""},{"help":"Enter mandal, taluka or town name","type":"text","label":"Mandal/Taluka/Town","options":[],"required":false,"pdf_field":""},{"help":"Enter district name","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter annual income in rupees","type":"amount","label":"Life Insured's Annual Income Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth in dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married","Widow(er)","Divorced"],"required":false,"pdf_field":""},{"help":"Select document submitted as proof of age","type":"choice","label":"Age Proof","options":["School Certificate","Voter ID/Ration Card","Others"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Enter sum insured amount within specified limits","type":"amount","label":"Sum Insured (Rs. in figures) (Min. ₹ 7,500 - Max. ₹ 3,00,000)","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium (Rs. In figures)","options":[],"required":true,"pdf_field":""},{"help":"Select mode of premium payment","type":"choice","label":"Preferred Mode of Payment","options":["Cash","Demand Draft","Cheque","Others"],"required":true,"pdf_field":""},{"help":"Select policy and premium payment term","type":"choice","label":"Policy Term (PT) and Premium Payment Term (PPT)","options":["PT: 8 years, PPT: Single","PT: 9 years, PPT: 5 years","PT: 10 years, PPT: 7 years","PT: 15 years, PPT: 10 years"],"required":true,"pdf_field":""},{"help":"Select how often premium is paid","type":"choice","label":"Premium Payment Frequency","options":["Single","Half yearly","Annually"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of the Nominee (Under section 39 of the Insurance Act 1938)","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee to insured","type":"text","label":"Relationship to the Life to be Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth if minor","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's address","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Fill details below only if nominee is minor","type":"section","label":"If Nominee is a Minor, please give appointee details below.","options":[],"required":null,"pdf_field":""},{"help":"Enter name of appointee for minor nominee","type":"text","label":"Name of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Enter relationship of appointee to minor nominee","type":"text","label":"Relationship to the Minor","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's address","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Appointee must sign here","type":"signature","label":"Signature of the Appointee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration of Good Health","fields":[{"help":"Answer if you are currently in good health","type":"yes-no","label":"A. Are you in good health?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer if you have had any of these conditions","type":"yes-no","label":"B. Have you ever had a heart condition, a stroke, hypertension, paralysis, cancer, diabetes, kidney disease, liver disease, mental illness, HIV infection or AIDS, high cholesterol, blood disorder, respiratory disorder, and nervous disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer about medication or illness in last 5 years","type":"yes-no","label":"C. Are you currently taking any medication or drugs, other than for minor conditions, or have you suffered from any illness, disorder, disability or injury during the past 5 years which required medical examination, consultation, hospitalisation or surgery?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer if currently pregnant","type":"yes-no","label":"E. Are you currently pregnant? (If applicable)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer / life to be insured"},{"title":"Declaration by Life to be Insured / Proposer","fields":[{"help":"Sign or provide thumb impression here","type":"signature","label":"Signature/Thumb impression of Life to be Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Write the declaration in your mother tongue in the provided box","type":"text","label":"Vernacular Declaration (to be handwritten by the life to be insured/proposer)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer / life to be insured"},{"title":"Declaration by the person filling in the form","fields":[{"help":"Enter name and address of declarant","type":"text","label":"Declarant's Name and Address","options":[],"required":true,"pdf_field":""},{"help":"Declarant must sign here","type":"signature","label":"Signature of declarant","options":[],"required":true,"pdf_field":""},{"help":"Adviser must sign here","type":"signature","label":"Signature of Adviser","options":[],"required":true,"pdf_field":""}],"filled_by":"person filling the form if different from proposer"},{"title":"Customer Information Report (To be filled by Adviser)","fields":[{"help":"Confirm if you met the proposer","type":"yes-no","label":"1. Did you personally meet the life to be Insured?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select identity proof seen","type":"choice","label":"2. What proof of Identity have you seen of the Life Insured?","options":["Driving License","Voter ID Card","Aadhar Card","Others please specify"],"required":true,"pdf_field":""},{"help":"Confirm satisfaction with proposer's answers","type":"yes-no","label":"3. Are you satisfied with the responses given by the proposer on proposal form including the DGH section?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Confirm satisfaction with income proof","type":"yes-no","label":"4. Proof of Income: Are you satisfied with the income declaration made by the Life Insured?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select income proofs checked","type":"choice","label":"a. If yes, what proofs of Income have you checked?","options":["Income Tax Return","Form 16","Property/Land Holding Detail","Others please specify"],"required":false,"pdf_field":""},{"help":"Disclose any relevant information for underwriting","type":"yes-no","label":"5. Is there anything in the life to be insured's occupation, life style, financial or social position or other circumstances that you feel the underwriter should be aware of?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide details if above answer is yes","type":"text","label":"If Yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Confirm if nominee depends on proposer","type":"yes-no","label":"6. Is the nominee dependent of the proposer? If No, please give details","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Enter adviser's name","type":"text","label":"Adviser Name","options":[],"required":true,"pdf_field":""},{"help":"Enter adviser's code","type":"text","label":"Adviser Code","options":[],"required":true,"pdf_field":""},{"help":"Enter date of filling","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Adviser must sign here","type":"signature","label":"Signature of Adviser","options":[],"required":true,"pdf_field":""}],"filled_by":"adviser"}],"deadlines":[],"applies_to":"Aviva Sampoorna Suraksha life insurance policy proposals","attachments":["Proof of age document","Proof of income documents (if applicable)","Identity proof documents","Initial payment (cash, cheque, or demand draft)"],"declarations":["The proposer confirms understanding of the product and proposal form and submits it voluntarily.","Statements and declarations in the form form the basis of the contract and untrue statements may lead to policy cancellation.","Any changes in statements or material facts before policy issuance must be informed in writing to the Company.","Payments made through advisers are only valid when received and realized by the Company within stipulated time.","Consent is given to share personal and medical information with the Company and related parties for underwriting and promotional purposes.","The proposer understands that policy sent by post is deemed delivered within three business days.","The declarant confirms having explained the proposal form contents to the proposer who understood them fully.","The adviser confirms having met the proposer, verified identity and income proofs, and is satisfied with the information provided."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customerservices@avivaindia.com","label":"General Enquiries- Customer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"stomer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"email","value":"weconnect@avivaindia.com","label":"General Enquiries- Partner Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Senior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-103-7766","label":"General Enquiries- Customer Toll Free","level":null,"hours":"All Days","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Jeevan Bima Plan\nGuaranteed Savings Plan\nULIP Plans\nPAY PREMIUM\nGeneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\ns","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"0124-2709046","label":"General Enquiries- Customer","level":null,"hours":"All Days","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Guaranteed Savings Plan\nULIP Plans\nPAY PREMIUM\nGeneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@av","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-103-8000","label":"Call (Toll Free) - For Kerala users","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"eneral Enquiries- Customer\nCall (All Days & Toll Free)\n1800-103-7766\n,\n0124-2709046\nCall (Toll Free) - For Kerala users\n1800-103-8000\nEmail\ncustomerservices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-180-2111","label":"General Enquiries- Partner Toll Free","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"vices@avivaindia.com\nSenior Citizen\nseniorcitizen@avivaindia.com\nGeneral Enquiries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 99","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"0124-2709000/46","label":"Corporate Office Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"Office\n401-A, 4th Floor,\nBlock A, DLF Cyber Park,\nSector-20, NH-8, Gurugram,\nHaryana-122 016, India.\nTelephone Number:\n0124-2709000/46\nEmail:\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-767757677","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"+91-7677576775","label":"Give a Missed Call","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"24-2709000/46\nEmail:\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-7677576775\nSMS\n\"Aviva\"to 5676737\nInsurance is the subject matter of the solicitation.\nIRDAI Reg No.\n122\n|\nCIN\n              :\nU660","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"sms","value":"\"Aviva\"to 5676737","label":"SMS Service","level":null,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":":\ncustomerservices@avivaindia.com\nToll Free Helpline:\n18001037766\n,\n0124-2709046\nGive a Missed Call:\n+91-7677576775\nSMS\n\"Aviva\"to 5676737\nInsurance is the subject matter of the solicitation.\nIRDAI Reg No.\n122\n|\nCIN\n              :\nU66010DL2000PLC107880\nAviv","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"complaints@avivaindia.com","label":"Contact Grievance Officer Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"iries- Partner\nCall (All Days & Toll Free)\n1800-180-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor\nsearch\nTERM","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91 9999346907","label":"Contact Grievance Officer Phone","level":1,"hours":"Mon-Fri, 9am-6pm","applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"0-2111\nEmail\nweconnect@avivaindia.com\nContact Grievance Officer\nEmail\ncomplaints@avivaindia.com\nCall (Mon-Fri, 9am-6pm)\n+91 9999346907\nCustomer\nGroup\nAdvisor\nsearch\nTERM\n                                                            INSURANCE\nAviva Smart Re","fetched_at":"2026-10-20"},{"purpose":"gro","channel":"address","value":"401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016","label":"Complaint Redressal Officer (CRO) Address","level":2,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"examine your issues and provide you impartial resolution. The CRO can be reached at :\nComplaint Redressal Officer(CRO).\n401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016\nEmail :\ncro@avivaindia.com\nLevel 3\n: Insurance Ombudsman Scheme.\nThe insurance Ombudsman is empowered to receive and co","fetched_at":"2026-10-20"},{"purpose":"gro","channel":"email","value":"cro@avivaindia.com","label":"Complaint Redressal Officer (CRO) Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.avivaindia.com/grievance-mechanism","quote":"edressal Officer(CRO).\n401-A, 4th Floor, Block A, DLF Cyber Park, Sector- 20, NH- 8, Gurugram, Haryana - 122016\nEmail :\ncro@avivaindia.com\nLevel 3\n: Insurance Ombudsman Scheme.\nThe insurance Ombudsman is empowered to receive and consider complaints from any","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/aviva-life-insurance/2080-proposal-form-for-aviva-sampoorna-suraksha"}