{"id":2672,"title":"Proposal Form - ‘Group Care 360 ’","purpose":"proposal","insurer":{"slug":"care-health-insurance","name":"Care Health Insurance Ltd"},"source_pdf":"https://cms.careinsurance.com/cms/public/uploads/download_center/group-care-360-(group-insurance-product)---proposal-form.pdf","sha256":"f283162e1e68302a25c2eccc30ac5c210012779081a845d07bba8412ece3ed18","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer (policyholder) to apply for the Group Care 360 group insurance policy from Care Health Insurance Limited.","notes":["Fill the form in CAPITAL LETTERS only.","Use additional sheets if space is insufficient.","Attach all required KYC documents as per Appendix 1.","The company may reject the proposal and refund premium if information is incomplete or discrepant.","The receipt of payment is only an acknowledgement and does not amount to acceptance of risk or commencement of policy.","Payment instruments should be drawn in favour of 'Care Health Insurance Ltd.'","The form includes statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938.","The proposer must provide complete details of all proposed insured members as per Annexure I.","Optional benefits and extensions must be selected and detailed as per Annexure II."],"title":"Proposal Form - ‘Group Care 360 ’","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"choice","label":"Do all the members proposed to be insured form part of one Group or Association or Corporate body?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is the scheme contributory","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Identification No. / Bank Account No. / any other","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN number and attach required KYC documents as per Appendix 1","type":"text","label":"PAN (mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Incorporation/Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full name of the Proposer/Entity","options":[],"required":null,"pdf_field":""},{"help":"Tick if correspondence address is same as permanent address","type":"checkbox","label":"Correspondence Address : (if same as above please tick here)","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Additional Information","fields":[{"help":"Use additional sheets if space is insufficient","type":"text","label":"Any additional information relevant to the policy applied for","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Past Policy and Claim Details","fields":[{"help":"Answer if declined to continue, not invited renewal, or imposed restrictions","type":"yes-no","label":"Condition(s) applicable to your health insurance policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details for past 3 policy periods","type":"text","label":"Name of Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"Provide insurer address for past 3 policy periods","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Policy number for past 3 policy periods","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Details of the Proposed to be Insured","fields":[{"help":"Fill Annexure I for all members proposed for insurance","type":"attachment","label":"Please provide complete details of Proposed to be Insured as per Annexure- I attached","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Policy Details","fields":[{"help":"","type":"choice","label":"Coverage Type","options":["Individual","Family"],"required":true,"pdf_field":""},{"help":"Number of members in family coverage","type":"number","label":"If Family coverage type is opted, then the Member Combination chosen: Members","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Geographical Scope","options":["India","Worldwide excluding India","Worldwide excluding US, Canada, India"],"required":null,"pdf_field":""},{"help":"Attach Annexure II for optional benefits/extensions chosen","type":"attachment","label":"Details of Optional Benefit(s) and Optional Extension(s) as per Final quote and/or Annexure – II","options":[],"required":null,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Acknowledgement for Proposal","fields":[{"help":"Filled by insurer as receipt acknowledgement","type":"text","label":"Receipt of payment of `________________ vide Cheque/DD No.____________________________ from M/S._______________________________________________","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Representative","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Representative","options":[],"required":null,"pdf_field":""}],"filled_by":"Care Health Insurance Representative"},{"title":"Declaration","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Authorized Signatory","options":[],"required":true,"pdf_field":""}],"filled_by":"Authorized Signatory of Proposer"},{"title":"Addendum - Vernacular Declaration","fields":[{"help":"Date of declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Declarant","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Declarant","options":[],"required":null,"pdf_field":""}],"filled_by":"Declarant"},{"title":"Section B : Corporate Declaration","fields":[{"help":"","type":"signature","label":"Signature of the Authorized Personnel","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Primary Insured Member","options":[],"required":true,"pdf_field":""}],"filled_by":"Applicant’s Authorized Personnel"},{"title":"Premium Payment Information","fields":[{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Payment Amount (INR)","options":[],"required":true,"pdf_field":""},{"help":"Specify payment mode and number","type":"text","label":"Payment By : Cheque / Demand Draft No. / Any other Mode (Strike out whichever is not applicable)","options":["Cheque","Demand Draft","Any other Mode"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Provide cheque or draft number or authorization ID","type":"text","label":"Cheque / Demand Draft No. / Authorization ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"}],"deadlines":[],"applies_to":"Group insurance policies under the Group Care 360 product","attachments":["Annexure I - Enrollment Data","Annexure II - Coverage Opted for – Optional Benefit / Optional Extension","KYC documents as per Appendix 1"],"declarations":["The statements and particulars given are true and complete to the best of the proposer’s knowledge and the proposer is authorized to propose on behalf of all persons proposed to be insured.","The policy will come into force only after full payment of the premium chargeable.","The proposer will notify in writing any change in occupation or general health after submission of proposal but before risk acceptance.","The company is authorized to seek medical information from doctors, hospitals, insurers, and government/regulatory authorities for underwriting and claim settlement.","The proposer consents to receiving information from Central CKYC Registry via SMS/Email.","The proposer maintains KYC details of all individual policyholders and will provide them to Care Health Insurance as required."],"dropped_labels":28},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/care-health-insurance/2672-proposal-form-group-care-360"}