{"id":2274,"title":"PROPOSAL FORM National Super Top Up Mediclaim Policy","purpose":"proposal","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NSTUMP%20Proposal.pdf","sha256":"12bc2d1329035f9da87daef604a73488c95cdd3e323d769f32ba0f197ef04573","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is for individuals proposing to purchase or renew the National Super Top Up Mediclaim Policy. The proposer fills it with personal, nominee, policy, and health details.","notes":["All fields are mandatory; do not leave any blank or put dashes.","Details of proposer and up to 5 insured persons can be filled; affix one stamp size photo per person.","Use separate form for additional nominees.","Strike through options not required where indicated.","Waiting period of 3 years applies for pre-existing diseases listed.","Use block letters where applicable.","Refer Annexure C for list of acceptable identity and residence proofs."],"title":"PROPOSAL FORM National Super Top Up Mediclaim Policy","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Insured Details","fields":[{"help":"Select your title","type":"choice","label":"Mr. Ms. Mrs.","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter your occupation or business","type":"text","label":"Occupation/Business/Service/Other:","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number if available","type":"text","label":"PAN No:","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhaar number","type":"text","label":"Aadhaar No:","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number","type":"text","label":"ABHA No:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address / Contact Details","fields":[{"help":"Enter mobile phone number","type":"phone","label":"Mobile No:","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":true,"pdf_field":""},{"help":"Enter current residential address","type":"text","label":"Present Address:","options":[],"required":true,"pdf_field":""},{"help":"Enter district of present address","type":"text","label":"District:","options":[],"required":true,"pdf_field":""},{"help":"Enter state of present address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin:","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent residential address","type":"text","label":"Permanent Address:","options":[],"required":true,"pdf_field":""},{"help":"Enter district of permanent address","type":"text","label":"District:","options":[],"required":true,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of Nominee:","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth (dd/mm/yyyy)","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of nominee if available","type":"text","label":"PAN no:","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number of nominee","type":"phone","label":"Mobile:","options":[],"required":false,"pdf_field":""},{"help":"Enter email ID of nominee","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Enter guardian's name if nominee is minor","type":"text","label":"Name of Guardian (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage share for nominee","type":"number","label":"Percentage of claim amount payable:","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Present Address:","options":[],"required":true,"pdf_field":""},{"help":"District of nominee's present address","type":"text","label":"District:","options":[],"required":true,"pdf_field":""},{"help":"State of nominee's present address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"PIN code of nominee's present address","type":"number","label":"Pin:","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Permanent Address:","options":[],"required":true,"pdf_field":""},{"help":"District of nominee's permanent address","type":"text","label":"District:","options":[],"required":true,"pdf_field":""},{"help":"State of nominee's permanent address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"PIN code of nominee's permanent address","type":"number","label":"Pin:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Strike through the one not required","type":"choice","label":"Policy Type:","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Strike through the one not required","type":"choice","label":"Is TPA service required?:","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Enter name as per bank account","type":"text","label":"Name in Bank Account:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch:","options":[],"required":true,"pdf_field":""},{"help":"Enter savings bank account number","type":"text","label":"SB Account No:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Enter number in figures and words","type":"number","label":"No. of persons covered (including proposer)","options":[],"required":true,"pdf_field":""},{"help":"Affix one stamp size photo per insured person","type":"photo","label":"Paste one stamp sized photographs and sign below","options":[],"required":true,"pdf_field":""},{"help":"Fill names of proposer and insured persons in table","type":"table","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Fill date of birth for each insured person","type":"table","label":"Date of Birth (mm/dd/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Fill age for each insured person","type":"table","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Specify gender for each insured person","type":"table","label":"Gender (M/F/Other)","options":["M","F","Other"],"required":true,"pdf_field":""},{"help":"Enter height in centimeters","type":"table","label":"Height (cm)","options":[],"required":true,"pdf_field":""},{"help":"Enter weight in kilograms","type":"table","label":"Weight (kg)","options":[],"required":true,"pdf_field":""},{"help":"Enter blood group","type":"table","label":"Blood Group","options":[],"required":true,"pdf_field":""},{"help":"Enter marital status","type":"table","label":"Marital Status","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"table","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Indicate if dependent","type":"table","label":"Dependent (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Enter occupation","type":"table","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Indicate smoking habit","type":"table","label":"Do you smoke? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Indicate alcohol consumption","type":"table","label":"Do you drink alcohol? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Enter threshold amount; applies to entire family if floater","type":"amount","label":"*Threshold","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount; applies to entire family if floater","type":"amount","label":"*Sum Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Particulars","fields":[{"help":"Indicate if base policy exists","type":"yes-no","label":"Is there an active Base Policy covering any/ all of the insured persons for hospitalisation? Yes/ No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide policy number(s) if yes","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Specify policy type","type":"choice","label":"Floater/ Ind","options":["Floater","Individual"],"required":false,"pdf_field":""},{"help":"List members covered with sum insured and cumulative bonus","type":"text","label":"Members covered with SI and CB","options":[],"required":false,"pdf_field":""},{"help":"Name of the policy","type":"text","label":"Policy Name","options":[],"required":false,"pdf_field":""},{"help":"Expiry date of base policy","type":"date","label":"Expiry Date","options":[],"required":false,"pdf_field":""},{"help":"Date of last claim","type":"date","label":"Last Claimed Date","options":[],"required":false,"pdf_field":""},{"help":"Amount claimed last time","type":"amount","label":"Claimed Amount","options":[],"required":false,"pdf_field":""},{"help":"Indicate if porting requested","type":"choice","label":"Porting? (Y/ N)","options":["Y","N"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select payment mode","type":"choice","label":"Premium Paid by: Cash Cheque DD Others, specify","options":["Cash","Cheque","DD","Others"],"required":true,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter payment date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name if applicable","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"National Super Top Up Mediclaim Policy","attachments":["One stamp size photograph of each insured person","Cancelled cheque (supporting bank account details)","Pre policy check up reports (if applicable)","Copy of existing health insurance policies (if applicable)","Proof of identity (any one document listed in Annexure C)","Proof of residence (any one document listed in Annexure C)","Copy of IT Certificate/ IT Return (wherever applicable)","Pan Details (or Form 60 or 61 as per Rule 114B of the Income-tax Rule,1962 if PAN not available)"],"declarations":["The statements and particulars given are true and complete to the best of my knowledge.","The policy will come into force only after full receipt of the premium.","I will notify any change in occupation or health after submission but before acceptance.","I consent to the insurer seeking medical and insurance information for underwriting and claims.","I authorize sharing of proposal and medical records with regulatory authorities.","Incorrect information at any time will void the policy and forfeit premiums."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customer.support@nic.co.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh Contrast\nInvert\nSaturation","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"18003450330","label":"Toll-Free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"033-22022100","label":"Head Office Telephone","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"d and Head Office\nPremises No. 18-0374, Plot No. CBD-81,\nNew Town, Kolkata-700156\nCIN: U10200WB1906GOI001713\nTelephone: 033-22022100\nFacebook\ninstagram\nX (Twitter)\nyoutube\nlinkedin\nWhatsapp\nBEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS /FRAUDULENT OFFE","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"9920501906","label":"WhatsApp Us","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/contact-us","quote":"h Us For Answers And Assistance—Your Gateway To Communication With Our Team.\nCustomer Service\n1800 345 0330\nWhatsApp Us\n9920501906\nHead Office\nPremises No. 18-0374, Plot No. CBD-81, New Town,  Kolkata - 700156\nTelephone: 033-22022100\nNote: Official c","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156","label":"Grievance Redressal Postal Address","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"e: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156 Insurance Ombudsman – As per Appendix attached to Policy. | 7\n12. | Things to Remember | Implied renewability (except o","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customer.relations@nic.co.in","label":"Grievance Redressal Officer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot no. CBD-81, New Town, Kolkata – 70015","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 345 0330","label":"Grievance Toll free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"holders Protection | • Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://nationalinsurance.nic.co.in/en/grievance","label":"Grievance Website","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"ice\n11. | Grievances/ Complaints | In case of any grievance the insured person may contact the company through Website: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No","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/national-insurance/2274-proposal-form-national-super-top-up-mediclaim-policy"}