{"id":2095,"title":"Proposal Form for Aviva Jana Suraksha","purpose":"proposal","insurer":{"slug":"aviva-life-insurance","name":"Aviva Life Insurance Company India Limited"},"source_pdf":"https://www.avivaindia.com/sites/default/files/JS%20Marathi%20Lmg.pdf","sha256":"540deb5d68b9666ab76612130d65e6e0c14768c8dd6d3442d447fc10421ae0e1","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals applying for the Aviva Jana Suraksha insurance policy. The proposer fills it to provide personal, nominee, and policy details to apply for life insurance coverage.","notes":["Fill all details in capital letters and black ink.","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 where required.","If the proposer is illiterate or signs in vernacular, a declarant must explain the form and record answers truthfully.","Section 41 and 45 of the Insurance Act 1938 apply regarding rebates and policy contestability."],"title":"Proposal Form for Aviva Jana Suraksha","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Deposit Details","fields":[{"help":"","type":"text","label":"Proposal Number प्रस्ताव क्रमांक","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Adviser Name सल्लागाराचे नाव","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Adviser Number सल्लागाराचा क्रमांक","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque or demand draft number if applicable","type":"text","label":"Cheque/DD No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount paid as initial deposit","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date दिनांक","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank or drawee","type":"text","label":"Drawn on काढलेल्या","options":[],"required":null,"pdf_field":""},{"help":"If you are an existing customer, enter your customer ID","type":"text","label":"Customer ID (for existing customer) ग्राहक क्रमांक विद्यमान ग्राहकासाठी","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Voucher Number व्हावचर क्रमांक","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Life to be Insured Details","fields":[{"help":"Select appropriate title","type":"choice","label":"Mr/Mrs/Miss/Ms श्री ६ सौ ६ श्रीमती","options":["Mr","Mrs","Miss","Ms"],"required":true,"pdf_field":""},{"help":"Enter given names in capital letters","type":"text","label":"Forenames दिलेले नाव","options":[],"required":true,"pdf_field":""},{"help":"Enter father's or husband's name","type":"text","label":"Father's/Husband's Name पित्याचेध्पतीचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Enter current residential address","type":"text","label":"Present Address वर्तमान पत्ता","options":[],"required":true,"pdf_field":""},{"help":"Enter village name","type":"text","label":"Village गव","options":[],"required":true,"pdf_field":""},{"help":"Enter taluka, mandal or town","type":"text","label":"Taluka/Mandal/Town तालुका ध्मंडळह नगर","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District जिल्हा","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State राज्य","options":[],"required":true,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode पिन कोड","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address if different from present address","type":"text","label":"Permanent Address (If different from above) कायमस्वरूपी पत्ता (जर वरीलपेक्षा वेगळे असेल तर)","options":[],"required":false,"pdf_field":""},{"help":"Select address for correspondence","type":"choice","label":"Address for Correspondence संपर्काचा पत्ता","options":["Present Address","Permanent Address"],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender लिंग","options":["Male पुरुष","Female ची"],"required":true,"pdf_field":""},{"help":"Enter date of birth (dd/mm/yyyy)","type":"date","label":"Date of Birth जन्मतारीख","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status वैवाहिक स्थिति","options":["Single अविवाहित","Married विवाहित","Widow(er) विधवा/विधुर","Divorced घटस्फोटीत"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer's Details (If different from life to be insured)","fields":[{"help":"Select appropriate title","type":"choice","label":"Mr/Mrs/Miss/Ms श्री ६ सौ ६ श्रीमती","options":["Mr","Mrs","Miss","Ms"],"required":false,"pdf_field":""},{"help":"Enter given names","type":"text","label":"Forenames दिलेले नाव","options":[],"required":false,"pdf_field":""},{"help":"Enter father's or husband's name","type":"text","label":"Father's/Husband's Name पित्याचेध्यतीचे नाव","options":[],"required":false,"pdf_field":""},{"help":"Enter current address","type":"text","label":"Present Address वर्तमान पत्ता","options":[],"required":false,"pdf_field":""},{"help":"Enter village","type":"text","label":"Village गव","options":[],"required":false,"pdf_field":""},{"help":"Enter taluka, mandal or town","type":"text","label":"Taluka/Mandal/Town तालुका ध्मंडळः नगर","options":[],"required":false,"pdf_field":""},{"help":"Enter district","type":"text","label":"District जिल्हा","options":[],"required":false,"pdf_field":""},{"help":"Enter state","type":"text","label":"State राज्य","options":[],"required":false,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode पिन कोड","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth (dd/mm/yyyy)","type":"date","label":"Date of Birth जन्मतारीख","options":[],"required":false,"pdf_field":""},{"help":"Select relationship to the life to be insured","type":"choice","label":"Relationship to the Life to be insured संरक्षित केल्या जाणा-या जीवनाशी असलेले नाते","options":["Father","Mother","Spouse","Legal Guardian","Others"],"required":false,"pdf_field":""},{"help":"Enter annual income in rupees","type":"amount","label":"Income per annum (Rs. in figures) वार्षिक उत्पन्न","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Enter sum insured in rupees","type":"amount","label":"Sum Insured (Rs. in figures) इंश्यअर्ड रक्कम (रु. आकड्यांमध्ये)","options":[],"required":true,"pdf_field":""},{"help":"Select premium payment frequency","type":"choice","label":"Premium frequency प्रीमियमची वारंवारिता","options":["Single Premium एकेरी प्रीमियम","Annual Premium वार्षिक प्रीमियम"],"required":true,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Premium (Rs. in figures) प्रीमियम (रु. आकड्यामध्ये)","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Preferred Mode of Payment भरणा प्राधान्य प्रकार","options":["Cash रोख","Cheque जिल्हा","Demand Draft जिल्हा"],"required":true,"pdf_field":""},{"help":"Select policy term in years","type":"choice","label":"Term in years वर्षातील मुदत","options":["5 Years वर्षे","10 Years वर्षे"],"required":true,"pdf_field":""},{"help":"Enter date of proposal","type":"date","label":"Date तारीख","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of the Nominee नामनिर्देशित व्यक्तीचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee to insured","type":"text","label":"Relationship to the Life to be insured संरक्षित केल्या जाणा-या जीवनाशी असलेले नाते","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth if minor","type":"date","label":"Date of Birth जन्मतारीख","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's address","type":"text","label":"Address पत्ता","options":[],"required":true,"pdf_field":""},{"help":"If nominee is minor, enter appointee's name","type":"text","label":"Name of the Appointee नियुक्त व्यक्तीचे नाव","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's date of birth","type":"date","label":"Date of Birth जन्मतारीख","options":[],"required":false,"pdf_field":""},{"help":"Enter relationship of appointee to minor nominee","type":"text","label":"Relationship to the Minor नाबालिक व्यक्तीचे नाते","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's address","type":"text","label":"Address पत्ता","options":[],"required":false,"pdf_field":""},{"help":"Appointee's signature if nominee is minor","type":"signature","label":"Signature of the Appointee नामनिर्देशित व्यक्तीची स्वाक्षरी","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration of Good Health","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Have you had a heart condition, diabetes, a stroke, cancer, HIV infection or AIDS? Are you currently in hospital and/or receiving medical treatment or advice? तुमच्याला यापूर्वी हृदयाचे आजार, आघात, उच्च रक्तदाब, अर्धांगवायू, कर्करोग, मधुमेह, किडनीचे कार्य बंद होणे, यकृताचे कार्य बंद होणे, मानसिक आजार, एचआयव्ही किंवा एड्स झाले आहे का? सध्या तुम्ही हॉस्पिटलमध्ये भरती वर्धकिंवा वैद्यकीय उपचार किंवा सल्ला घेत आहात?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Have you been absent from work or taken leave for ten days or more on health grounds over the last one year? तुम्ही कामावर अनुपस्थित राहिला आहात का किंवा 10 दिवसासाठी रजा घेतली आहे किंवा मागील वर्षभरात आरोग्याच्या कारणास्तव रजा घेतली आहे का?","options":["YES","NO"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Signature or thumb impression of the life to be insured","type":"signature","label":"Signature/Thumb impression of Life to be insured विम्या कर्त्याची स्वाक्षरी धअंगठ्याचा ठसा","options":[],"required":true,"pdf_field":""},{"help":"Signature or thumb impression of proposer if different from life to be insured","type":"signature","label":"Signature/Thumb impression of proposer (If other than Life to be Insured) स्वाक्षरी ध्वविम्या कर्त्याचा अंगठ्याचा ठसा जर संरक्षित केल्या जाणाया जीवनापेक्षा वेगळाद्ध","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date दिनांक","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place ठिकाण","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and life to be insured"},{"title":"Declaration by the person filling in the form","fields":[{"help":"Indicate if photo ID is available","type":"choice","label":"ID available आय डी (ओळखपत्र) उपलब्ध","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter ID number","type":"text","label":"ID No. आय डी क्रमांक","options":[],"required":false,"pdf_field":""},{"help":"Enter declarant's full name and address","type":"text","label":"Declarant's name & address घोषणा करणाऱ्याचे नाव व पत्ता","options":[],"required":true,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode पिन कोड","options":[],"required":true,"pdf_field":""},{"help":"Date of issue of ID","type":"date","label":"Date of issue दिल्याची तारीख","options":[],"required":false,"pdf_field":""},{"help":"Declarant's signature","type":"signature","label":"Signature of declarant घोषणा करणाऱ्याची स्वाक्षरी","options":[],"required":true,"pdf_field":""}],"filled_by":"declarant"}],"deadlines":[],"applies_to":"Aviva Jana Suraksha life insurance policy proposals","attachments":["Proof of age document","Photo ID of declarant","Initial payment receipt"],"declarations":["I fully understand the meaning and scope of the proposal form and submit it on my own accord without inducement.","The statements and material facts in this form form the basis of the insurance contract and any untrue information may lead to policy cancellation and forfeiture of payments.","I will inform the company in writing of any changes in statements or facts until the policy is issued, else the policy may be cancelled.","Payments made through an adviser are only valid once received and realized by the company within stipulated time.","I consent to the company obtaining and sharing my personal and medical information for underwriting and verification purposes.","If the policy is sent by post, it is deemed delivered within three business days.","An illustration of the policy has been shown to me by the company representative."],"dropped_labels":4},"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/2095-proposal-form-for-aviva-jana-suraksha"}