{"id":2276,"title":"PROPOSAL FORM National Senior Citizen 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/NSCMP%20-%20Proposal%20Form.pdf","sha256":"780eaeebbfc9401f04fe4f71b7ccbc727fb86890bed70dd5a0af6dd0d12ea684","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) applying for a new or renewal National Senior Citizen Mediclaim insurance policy. The proposer fills it to provide personal, nominee, policy, health, and payment details for underwriting and policy issuance.","notes":["All fields are mandatory; do not leave any field blank or put dashes.","Affix one stamp size photograph of each person on the form.","Use separate form for additional nominees.","Sum Insured options are INR 1L to 10L per individual or family.","Critical Illness and Personal Accident cover amounts should not exceed sum insured.","Use block letters for names where specified.","Portability form is required if porting from another insurer.","Attach original documents as per Annexure C for identity and residence proof.","Policy will be issued only after acceptance and premium payment."],"title":"PROPOSAL FORM National Senior Citizen Mediclaim Policy","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"Select whether this is a new policy or a renewal with changes","type":"choice","label":"Proposal for New Policy Renewal (with change in details)","options":["New Policy","Renewal (with change in details)"],"required":true,"pdf_field":""},{"help":"Enter start and end dates of the policy period","type":"date","label":"Policy Period: From To midnight of","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Details","fields":[{"help":"Select appropriate title","type":"choice","label":"Mr. Ms. Mrs.","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Full name of the proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Specify occupation or business","type":"text","label":"Occupation/Business/Service/Other","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No","options":[],"required":true,"pdf_field":""},{"help":"12-digit Aadhaar number","type":"text","label":"Aadhaar No","options":[],"required":true,"pdf_field":""},{"help":"Ayushman Bharat Health Account number if available","type":"text","label":"ABHA No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address / Contact Details","fields":[{"help":"Mobile phone number","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID","options":[],"required":true,"pdf_field":""},{"help":"Full present address including district, state, and pin code","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address including district, state, and pin code","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Nominee's date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"PAN number of nominee if available","type":"text","label":"PAN no","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of nominee","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email of nominee","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Guardian's name if nominee is a minor","type":"text","label":"Name of Guardian (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim amount for nominee","type":"number","label":"Percentage of claim amount payable","options":[],"required":true,"pdf_field":""},{"help":"Nominee's present address including district, state, and pin code","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Nominee's permanent address including district, state, and pin code","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Select policy type; strike through the one not required","type":"choice","label":"Policy Type","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Indicate if Third Party Administrator service is required","type":"yes-no","label":"Is TPA service required?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select plan A or B","type":"choice","label":"Plan","options":["A","B"],"required":true,"pdf_field":""},{"help":"Select zone as per location","type":"choice","label":"Zone","options":["Zone 1","Zone 2"],"required":true,"pdf_field":""},{"help":"Indicate if co-payment is opted","type":"yes-no","label":"Is Co-payment opted?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Name as per bank account","type":"text","label":"Name in Bank Account","options":[],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Savings bank account number","type":"text","label":"SB Account No","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Number of persons covered in figures and words","type":"number","label":"No. of persons covered (including proposer)","options":[],"required":true,"pdf_field":""},{"help":"Customer code if available","type":"text","label":"Customer Code","options":[],"required":true,"pdf_field":""},{"help":"Date of birth in mm/dd/yyyy format","type":"date","label":"Date of Birth (mm/dd/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (M/F)","options":["M","F"],"required":true,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (cm)","options":[],"required":true,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight (kg)","options":[],"required":true,"pdf_field":""},{"help":"Blood group","type":"text","label":"Blood Group","options":[],"required":true,"pdf_field":""},{"help":"Marital status","type":"text","label":"Marital Status","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Is the person dependent?","type":"yes-no","label":"Dependent (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Occupation of the insured person","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Indicate smoking habit","type":"yes-no","label":"Do you smoke? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Indicate alcohol consumption","type":"yes-no","label":"Do you drink alcohol? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Select sum insured per individual or family","type":"choice","label":"Sum Insured (SI)","options":["INR 1L","INR 2L","INR 3L","INR 4L","INR 5L","INR 6L","INR 7L","INR 8L","INR 9L","INR 10L"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Particulars","fields":[{"help":"Indicate if any existing base policy is active","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":"Existing policy number if applicable","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Name of existing insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Type of existing policy","type":"choice","label":"Floater/ Ind","options":["Floater","Individual"],"required":false,"pdf_field":""},{"help":"Details of 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 existing policy","type":"text","label":"Policy Name","options":[],"required":false,"pdf_field":""},{"help":"Expiry date of existing policy","type":"date","label":"Expiry Date","options":[],"required":false,"pdf_field":""},{"help":"Date of last claim under existing policy","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 existing policy","type":"yes-no","label":"Porting? (Y/ N)","options":["Y","N"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Opt for diabetes cover up to sum insured","type":"yes-no","label":"Diabetes (Write ‘Yes’ if required)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Opt for hypertension cover up to sum insured","type":"yes-no","label":"Hypertension (Write ‘Yes’ if required)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select outpatient treatment limit per family","type":"choice","label":"Outpatient Treatment (Write Limit of Cover required)","options":["INR 2,000","INR 4,000","INR 5,000","INR 7,500","INR 10,000","INR 15,000"],"required":false,"pdf_field":""},{"help":"Benefit amount per individual; must not exceed sum insured","type":"choice","label":"Critical Illness (Write Benefit Amount required per individual)","options":["INR 100,000","INR 200,000","INR 300,000","INR 400,000","INR 500,000","INR 600,000","INR 700,000","INR 800,000","INR 900,000","INR 1,000,000"],"required":false,"pdf_field":""},{"help":"Capital sum insured per individual; must not exceed sum insured","type":"choice","label":"Personal Accident (Write Capital Sum Insured required per individual)","options":["INR 100,000","INR 200,000","INR 300,000","INR 400,000","INR 500,000","INR 600,000","INR 700,000","INR 800,000","INR 900,000","INR 1,000,000"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of premium payment","type":"choice","label":"Premium Paid by: Cash Cheque DD Others, specify","options":["Cash","Cheque","DD","Others"],"required":true,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Bank name if payment by cheque or DD","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Certificate from Proposer","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of proposer or representative","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or representative"},{"title":"Medical Examination Report Part I: Personal History","fields":[{"help":"Name of insured person examined","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Describe current complaints and investigations","type":"text","label":"Present complaints and investigation, if any","options":[],"required":true,"pdf_field":""},{"help":"Provide past medical history with dates","type":"text","label":"Any past history of disease, operations, accidents, investigations with date, major medical complaints of hospitalisation?","options":[],"required":true,"pdf_field":""},{"help":"List medications and duration","type":"text","label":"Details of present and past medication with duration","options":[],"required":true,"pdf_field":""},{"help":"State cure status and treatment dates","type":"text","label":"Is he cured of diseases, if any? When was your treatment, if any, given, stopped?","options":[],"required":true,"pdf_field":""},{"help":"Findings of general examination","type":"text","label":"General examination","options":[],"required":true,"pdf_field":""},{"help":"Findings of systematic examination","type":"text","label":"Systematic examination","options":[],"required":true,"pdf_field":""},{"help":"Name and qualification of examiner","type":"text","label":"Name of Medical Examiner & qualification","options":[],"required":true,"pdf_field":""},{"help":"Registration number of medical examiner","type":"text","label":"Regd.No","options":[],"required":true,"pdf_field":""},{"help":"Address of medical examiner","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Medical examiner's signature","type":"signature","label":"Signature of Medical Examiner","options":[],"required":true,"pdf_field":""},{"help":"Date of medical examination","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Proposer's signature confirming report","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"consulting physician / surgeon"},{"title":"Portability Form","fields":[{"help":"Name of policyholder or insured","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Date of birth or age","type":"date","label":"Date of Birth/Age","options":[],"required":true,"pdf_field":""},{"help":"Full address","type":"text","label":"Address of the policyholder/insured","options":[],"required":true,"pdf_field":""},{"help":"Name of existing insurance product","type":"text","label":"Name of the product","options":[],"required":true,"pdf_field":""},{"help":"Sum insured under existing policy","type":"amount","label":"Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Cumulative bonus amount if any","type":"amount","label":"Cumulative Bonus","options":[],"required":false,"pdf_field":""},{"help":"List any add-ons or riders","type":"text","label":"Add-ons/riders taken","options":[],"required":false,"pdf_field":""},{"help":"Existing policy number","type":"text","label":"Policy number","options":[],"required":true,"pdf_field":""},{"help":"Sum insured proposed","type":"amount","label":"Sum Insured Proposed","options":[],"required":true,"pdf_field":""},{"help":"Indicate if cumulative bonus to be converted","type":"yes-no","label":"Whether Cumulative Bonus to be converted to an enhanced sum insured","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Explain reason for portability","type":"text","label":"Reason(s) for Portability","options":[],"required":true,"pdf_field":""},{"help":"Number of family members to port","type":"number","label":"No. of family members to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Attach photocopies of existing and previous policies","type":"attachment","label":"Photocopy of the existing & previous policy documents","options":[],"required":true,"pdf_field":""},{"help":"Indicate if waiting periods are longer","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy? (Please indicate Yes / NO)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Consent to observe additional waiting periods","type":"text","label":"If yes, please give written consent to the declaration below","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of policyholder","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"National Senior Citizen Mediclaim Policy","attachments":["One stamp size photograph of each 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 if PAN not available)","Photocopy of the existing & previous policy documents (for portability)"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will come into force only after receipt of premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The insurer is authorized to seek medical and insurance information for underwriting and claims.","The insurer may share proposal and medical information with government or regulatory authorities.","Incorrect information at any time during policy validity will void the policy and forfeit premiums.","No person shall offer or accept rebates except as allowed by the insurer's prospectus or tables."],"dropped_labels":5},"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/2276-proposal-form-national-senior-citizen-mediclaim-policy"}