{"id":2100,"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%20Malam-%20Lmg_0.pdf","sha256":"f6962192afb8df1108dc7a28fc5b40453f968eccea8486f4fc92e7cb4438e801","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals applying for the Aviva Jana Suraksha insurance policy. The proposer and the life to be insured fill it out.","notes":["Complete the form in CAPITAL LETTERS and BLACK INK.","Use original documents for proof of age.","If proposer signs in vernacular or is illiterate, a declarant must explain the form and record answers truthfully.","Refunds for cash deposits will be made by cheque only."],"title":"Proposal Form for Aviva Jana Suraksha","submit":{"to":"Branch Office or any other manner as may be approved by the Company","how":"In person or as approved by the Company","address":""},"purpose":"proposal","sections":[{"title":"Proposal Deposit Details","fields":[{"help":"Enter the 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 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":"Select appropriate title","type":"choice","label":"Mr/Mrs/Miss/Ms","options":["Mr","Mrs","Miss","Ms"],"required":true,"pdf_field":""},{"help":"Enter surname in capital letters","type":"text","label":"Surname","options":[],"required":true,"pdf_field":""},{"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 permanent address if different from present address","type":"text","label":"Permanent Address (If different from above)","options":[],"required":false,"pdf_field":""},{"help":"Select address to be used for correspondence","type":"choice","label":"Address for Correspondence","options":["Present Address","Permanent Address"],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married","Widow(er)","Divorced"],"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","options":["Mr","Mrs","Miss","Ms"],"required":false,"pdf_field":""},{"help":"Enter surname","type":"text","label":"Surname","options":[],"required":false,"pdf_field":""},{"help":"Enter forenames","type":"text","label":"Forenames","options":[],"required":false,"pdf_field":""},{"help":"Enter father's or husband's name","type":"text","label":"Father's/Husband's Name","options":[],"required":false,"pdf_field":""},{"help":"Select relationship","type":"choice","label":"Relationship to the Life to be insured","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)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured (Rs. in figures)","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium (Rs. in figures)","options":[],"required":true,"pdf_field":""},{"help":"Enter policy term in years","type":"number","label":"Term in years","options":[],"required":true,"pdf_field":""},{"help":"Select premium payment frequency","type":"choice","label":"Premium frequency","options":["Single Premium","Annual Premium"],"required":true,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Preferred Mode of Payment","options":["Cash","Cheque","Demand Draft"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination Details (To be completed only when the proposer and the life to be insured are the same)","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee to life insured","type":"text","label":"Relationship to the Life to be insured","options":[],"required":true,"pdf_field":""},{"help":"Enter address of nominee","type":"text","label":"Address","options":[],"required":true,"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 name of appointee","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 address of appointee","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 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?","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?","options":["YES","NO"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Confirm if illustration was shown","type":"yes-no","label":"An illustration has been shown to me by the Company representative","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/Thumb impression of Life to be insured","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression if proposer is different","type":"signature","label":"Signature/Thumb impression of proposer (If other than Life to be Insured)","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by the person filling in the form","fields":[{"help":"Enter declarant's full name and address","type":"text","label":"Declarant's name & address","options":[],"required":true,"pdf_field":""},{"help":"Enter pincode","type":"text","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"Declarant must sign here","type":"signature","label":"Signature of declarant","options":[],"required":true,"pdf_field":""},{"help":"Specify type of photo ID provided","type":"text","label":"ID available","options":[],"required":false,"pdf_field":""},{"help":"Enter photo ID number","type":"text","label":"ID No.","options":[],"required":false,"pdf_field":""},{"help":"Enter date of issue of photo ID","type":"date","label":"Date of issue","options":[],"required":false,"pdf_field":""}],"filled_by":"declarant"}],"deadlines":[],"applies_to":"Aviva Jana Suraksha insurance policy proposals","attachments":["Initial payment (cash, crossed cheque or demand draft payable to Aviva Life Insurance Account Proposal Number)","Proof of age document"],"declarations":["The proposer must be satisfied with product details and pay initial payment with the proposal.","Receipt of proposal and payment does not create obligation until underwriting and policy issuance.","Omission or misrepresentation of information may void the policy.","Proof of age is mandatory.","The proposer consents to the Company verifying medical and personal information from any source.","The policy sent by post is deemed delivered within three business days.","The proposer confirms understanding and truthfulness of the proposal and declarations.","The proposer agrees to inform the Company of any changes until policy issuance.","Payments made through an Adviser are valid only when received and realized by the Company."],"dropped_labels":7},"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/2100-proposal-form-for-aviva-jana-suraksha"}