{"id":2104,"title":"Aviva Jana Suraksha - Oriya","purpose":"proposal","insurer":{"slug":"aviva-life-insurance","name":"Aviva Life Insurance Company India Limited"},"source_pdf":"https://www.avivaindia.com/sites/default/files/JS_Oriya.pdf","sha256":"944bd0654f803fc28524a93fc4a801c62871a0bb8f125a88e2b64f8f8731bc05","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used to apply for the Aviva Jana Suraksha insurance policy. It is filled by the proposer who may be the life to be insured or a different person.","notes":["This is a specimen form and not valid for application.","Nomination details are to be filled only if the proposer and life to be insured are the same person.","If the nominee is a minor, appointee details must be provided and signed.","Answer all health-related questions truthfully.","Refer to the Insurance Act, 1938 for full legal provisions."],"title":"Aviva Jana Suraksha - Oriya","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer's Details (If different from life to be insured)","fields":[{"help":"","type":"choice","label":"Mr/Mrs/Miss/Ms","options":["Mr","Mrs","Miss","Ms"],"required":null,"pdf_field":""},{"help":"Enter your family name","type":"text","label":"Surname","options":[],"required":null,"pdf_field":""},{"help":"Enter your given names","type":"text","label":"Forenames","options":[],"required":null,"pdf_field":""},{"help":"Enter your father's or husband's full name","type":"text","label":"Father's/Husband's Name","options":[],"required":null,"pdf_field":""},{"help":"Enter your current residential address","type":"text","label":"Present Address","options":[],"required":null,"pdf_field":""},{"help":"Enter your village name","type":"text","label":"Village","options":[],"required":null,"pdf_field":""},{"help":"Enter your post office","type":"text","label":"P.O.","options":[],"required":null,"pdf_field":""},{"help":"Enter your Taluka, Mandal or Town","type":"text","label":"Taluka/Mandal/Town","options":[],"required":null,"pdf_field":""},{"help":"Enter your district","type":"text","label":"District","options":[],"required":null,"pdf_field":""},{"help":"Enter your state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter your area's postal code","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Enter your date of birth in dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select your relationship to the insured person","type":"choice","label":"Relationship to the Life to be insured","options":["Father","Mother","Spouse","Legal Guardian","Others"],"required":null,"pdf_field":""},{"help":"Enter your annual income in rupees","type":"amount","label":"Income per annum (Rs. in figures)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Enter the sum insured amount in rupees","type":"amount","label":"Sum Insured (Rs. in figures)","options":[],"required":null,"pdf_field":""},{"help":"Enter the premium amount in rupees","type":"amount","label":"Premium (Rs. in figures)","options":[],"required":null,"pdf_field":""},{"help":"Select the policy term in years","type":"choice","label":"Term in years","options":["5 Years","10 Years","20 Years"],"required":null,"pdf_field":""},{"help":"Select how often you will pay the premium","type":"choice","label":"Premium frequency","options":["Single Premium","Annual Premium"],"required":null,"pdf_field":""},{"help":"Select your preferred payment mode","type":"choice","label":"Preferred Mode of Payment","options":["Cash","Cheque","Demand Draft"],"required":null,"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 the full name of the nominee","type":"text","label":"Name of the Nominee","options":[],"required":null,"pdf_field":""},{"help":"Enter the nominee's relationship to the insured","type":"text","label":"Relationship to the Life to be insured","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's date of birth in dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter the nominee's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Fill appointee details if nominee is underage","type":"section","label":"If Nominee is a Minor, please give appointee details below.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the appointee","type":"text","label":"Name of the Appointee","options":[],"required":null,"pdf_field":""},{"help":"Enter appointee's date of birth in dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter appointee's relationship to the minor nominee","type":"text","label":"Relationship to the Minor","options":[],"required":null,"pdf_field":""},{"help":"Enter the appointee's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Appointee must sign here","type":"signature","label":"Signature of the Appointee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Declaration","fields":[{"help":"Answer truthfully about your medical history and current treatment","type":"yes-no","label":"Have you ever had a heart condition, a stroke, hypertension, paralysis, cancer, diabetes, kidney failure, liver failure, mental illness, HIV infection or AIDS? Are you currently in hospital and/or receiving medical treatment or advice?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["No person shall offer or accept any rebate of commission or premium except as allowed by the insurer's published prospectus.","A life insurance policy cannot be questioned after three years from issuance or commencement of risk except on grounds of fraud.","The insurer must communicate in writing the grounds for repudiation of a policy on grounds of fraud or misstatement.","Premiums collected till repudiation on grounds other than fraud must be returned within ninety days.","The insurer may call for proof of age at any time and adjust policy terms accordingly."],"dropped_labels":0},"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/2104-aviva-jana-suraksha-oriya"}