{"id":2082,"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%20Bengali.pdf","sha256":"130e76196731e59fbe63c1d6e992bb5037e648dbf151774842591c9ebb678eb3","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Aviva Sampoorna Suraksha life insurance policy by providing personal, health, and policy details.","notes":["Fill all details in capital letters where specified.","Proof of age is mandatory.","Initial payment must accompany the proposal and can be paid by cash, crossed cheque or demand draft payable to Aviva Life Insurance Account Proposal Number.","Refunds for cash deposits will be made by cheque only.","Use original documents for proof and income declarations.","Section 41 and 45 of the Insurance Act 1938 apply regarding rebates and policy contestability.","The vernacular declaration must be handwritten by the proposer in their own language.","If the proposer signs in vernacular or thumb impression, the declaration must be made by a person of standing unconnected with the insurer."],"title":"Proposal Form for Aviva Sampoorna Suraksha","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Deposit Details","fields":[{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque/DD No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount paid","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"If you are an existing customer, enter your 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":"Enter the date of payment","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank or branch on which cheque/DD is drawn","type":"text","label":"Drawn on","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Life to be Insured Details","fields":[{"help":"Enter forenames 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 full mailing address","type":"text","label":"Mailing Address","options":[],"required":true,"pdf_field":""},{"help":"Enter village name","type":"text","label":"Village","options":[],"required":false,"pdf_field":""},{"help":"Enter post office","type":"text","label":"P.O.","options":[],"required":false,"pdf_field":""},{"help":"Enter Mandal, Taluka or Town","type":"text","label":"Mandal/Taluka/Town","options":[],"required":false,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"Enter state","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 occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Married","Divorced","Widow(er)","Others"],"required":true,"pdf_field":""},{"help":"Attach proof of age document","type":"attachment","label":"Age Proof","options":[],"required":true,"pdf_field":""},{"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":"Select policy term 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 premium payment frequency","type":"choice","label":"Premium Payment Frequency","options":["Single","Half yearly","Annually"],"required":true,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Preferred Mode of Payment","options":["Cash","Cheque","Draft","Demand","Others"],"required":true,"pdf_field":""},{"help":"Enter annual income","type":"amount","label":"Life Insured's Annual Income Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination Details","fields":[{"help":"Enter nominee's full name","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","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Fill appointee details if nominee is minor","type":"section","label":"If Nominee is a Minor, please give appointee details below.","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's name","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 to 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 listed serious illnesses","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 current medication or recent serious health issues","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 about recent absences or health restrictions","type":"yes-no","label":"D. Any illness that has caused you to be absent from work for a continuous period of 7 days or more in the last 2 years or has your health placed any restrictions on your normal daily activities?","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"},{"title":"Declaration","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 date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration","fields":[{"help":"Sign or thumb impression here","type":"signature","label":"Signature/Thumb impression of Life to be Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by the person filling in the form","fields":[{"help":"Enter name and address of the person filling the form","type":"text","label":"Declarant's Name and Address","options":[],"required":true,"pdf_field":""},{"help":"Declarant to sign here","type":"signature","label":"Signature of declarant","options":[],"required":true,"pdf_field":""},{"help":"Adviser to sign here","type":"signature","label":"Signature of Adviser","options":[],"required":true,"pdf_field":""},{"help":"Enter date of declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"declarant"},{"title":"Customer Information Report","fields":[{"help":"Adviser to confirm personal meeting","type":"yes-no","label":"Did you personally meet the life to be insured?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Adviser to tick all applicable proofs seen","type":"checkbox","label":"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":"Adviser to confirm satisfaction with income proof","type":"yes-no","label":"Proof of Income: Are you satisfied with the income declaration made by the Life Insured?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Adviser to specify income proofs checked","type":"checkbox","label":"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":"Adviser to disclose any relevant information","type":"yes-no","label":"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":"Adviser to confirm nominee dependency","type":"yes-no","label":"Is the nominee dependent of the proposer? If No, please give details","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide details if nominee is not dependent","type":"text","label":"Give details of the insurable interest that exist between the proposer and the nominee.","options":[],"required":false,"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 to 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","Income proof documents (if applicable)"],"declarations":["The proposer confirms understanding of the proposal form and submits it voluntarily.","Statements and declarations form the basis of the contract and untrue statements may lead to policy cancellation.","Any changes in statements or facts before policy issuance must be informed to the company in writing.","Payments made through advisers are only valid when received and realized by the company in time.","Consent is given for the company to collect and share personal and medical information for underwriting and promotional purposes.","If the proposal is not filled by the proposer, the contents have been fully explained and understood.","The proposer agrees to the declaration of good health questions truthfully.","The adviser declares that the proposal form contents have been fully explained and truthfully recorded."],"dropped_labels":6},"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/2082-proposal-form-for-aviva-sampoorna-suraksha"}