{"id":2107,"title":"Aviva Jana Suraksha - Kannada","purpose":"proposal","insurer":{"slug":"aviva-life-insurance","name":"Aviva Life Insurance Company India Limited"},"source_pdf":"https://www.avivaindia.com/sites/default/files/JS_Kannada.pdf","sha256":"dcf86af585f56ff5a87c1f1183df2b089cacef891da4e7f4fb9532166a2f293f","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a proposal form for the Aviva Jana Suraksha insurance plan, to be filled by the proposer and the life to be insured.","notes":["Form is specimen only and not valid for application","Nomination details to be filled only if proposer and life to be insured are the same","If nominee is minor, appointee details must be provided","Signatures or thumb impressions required from life to be insured and proposer","Declarant must provide photo ID details and sign","Section 45 of Insurance Act, 1938 applies as printed in the form"],"title":"Aviva Jana Suraksha - Kannada","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 surname","type":"text","label":"Surname","options":[],"required":null,"pdf_field":""},{"help":"Enter your forenames","type":"text","label":"Forenames","options":[],"required":null,"pdf_field":""},{"help":"Enter your father's or husband's name","type":"text","label":"Father's/Husband's Name","options":[],"required":null,"pdf_field":""},{"help":"Enter your current address including village, P.O., Taluka/Mandal/Town, District, State, and Pincode","type":"text","label":"Present Address","options":[],"required":null,"pdf_field":""},{"help":"Enter 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 life to be insured","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 term of the policy in years","type":"choice","label":"Term in years","options":["5 Years","10 Years"],"required":null,"pdf_field":""},{"help":"Select the premium payment frequency","type":"choice","label":"Premium frequency","options":["Annual Premium","Single Premium"],"required":null,"pdf_field":""},{"help":"Select your preferred mode of payment","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 life to be 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":"","type":"section","label":"If Nominee is a Minor, please give appointee details below.","options":[],"required":null,"pdf_field":""},{"help":"Enter the 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 the 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":"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":null,"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":null,"pdf_field":""}],"filled_by":"proposer and life to be insured"},{"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":null,"pdf_field":""},{"help":"Life to be insured must sign or thumb impression here","type":"signature","label":"Signature/Thumb impression of Life to be insured","options":[],"required":true,"pdf_field":""},{"help":"Proposer must sign or thumb impression here if different from life to be insured","type":"signature","label":"Signature/Thumb impression of proposer (If other than Life to be Insured)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer and life to be insured"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["I understand the proposal form and submit it on my own accord","Statements and facts are basis of contract and untrue info may lead to cancellation","I will inform company of any changes before policy issuance","Payments via adviser are only valid if received by company on time","I consent to sharing my medical and personal information for verification","I have been shown an illustration by the company representative","Declarant has explained the questions in vernacular and truthfully recorded answers"],"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/2107-aviva-jana-suraksha-kannada"}