{"id":2673,"title":"Group Care (Group Health Insurance Product) - Proposal Form","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-(group-health-insurance-product)---proposal-form.pdf","sha256":"b1aabd873e60b0c802178cf967f40d77ce5944a8c4d3626744818bdf63df42e6","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by entities or groups proposing to purchase group health insurance coverage from Care Health Insurance Limited. The proposer (entity or group representative) fills it to provide details about the group, insured persons, past policies, and coverage options.","notes":["Fill all questions fully and correctly; if not applicable, write 'Not Applicable' or 'NA'.","Fill in CAPITAL letters only.","Attach all required KYC documents as per Appendix 1.","Use original documents where applicable.","Cheque/Demand Draft should be drawn in favour of 'Care Health Insurance Ltd.'","Receipt of proposal form does not mean acceptance; policy starts only after underwriting and premium receipt.","Optional Extensions may require additional premium or discount; some are mutually exclusive.","Keep a copy of the acknowledgement receipt for records.","Refer to the policy for detailed exclusions and terms."],"title":"Group Care (Group Health Insurance Product) - Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Care Health Branch Details and Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Sales Manager Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Branch Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Business Sector","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary RM Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Client ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Receipt ID","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary or sales agent"},{"title":"Proposer Details","fields":[{"help":"Fill in capital letters","type":"text","label":"Full name of the Proposer/Entity","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nature of Business/Business Description","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number of the proposer entity","type":"text","label":"PAN (Mandatory )","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address for Communication","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Valid email address","type":"email","label":"E-mail","options":[],"required":true,"pdf_field":""},{"help":"Name of the contact person for the proposal","type":"text","label":"Key contact person name","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the contact person","type":"phone","label":"Contact details of Key Contact person","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do all the members proposed to be insured form part of one Group or Association or Corporate body?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the scheme contributory","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Total number of persons proposed for insurance","type":"number","label":"No. of persons to be Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Past Policy and Claim Details","fields":[{"help":"Name and address of previous insurance company","type":"text","label":"Name & Address of the Insurer","options":[],"required":null,"pdf_field":""},{"help":"Previous policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Extensions","fields":[{"help":"List optional extensions to be opted with sub limit, wait period, and Yes/No for opting","type":"table","label":"Description","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy and Claims Services","fields":[{"help":"Name of Third Party Administrator if applicable","type":"text","label":"Name (If TPA is selected)","options":[],"required":null,"pdf_field":""},{"help":"Select applicable option","type":"choice","label":"In House/TPA (strike out whichever is not applicable)","options":["In House","TPA"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposed Coverage and Payment Details","fields":[{"help":"Amount of premium proposed to be paid","type":"amount","label":"Premium Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Bank from which payment is made","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Select payment frequency","type":"choice","label":"Premium payment Frequency","options":["Single","Half Yearly","Quarterly","Monthly"],"required":true,"pdf_field":""},{"help":"Cheque or Demand Draft number","type":"text","label":"Instrument No.","options":[],"required":null,"pdf_field":""},{"help":"Date of cheque or demand draft","type":"date","label":"Instrument Date (DD/MM/YYYY)","options":[],"required":null,"pdf_field":""},{"help":"Specify mode of payment and details","type":"text","label":"Mode of Payment : Cheque/Demand Draft No./Any other Mode (Strike out whichever is not applicable)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Signature of authorized person proposing the insurance","type":"signature","label":"Signature of the Authorized Signatory","options":[],"required":true,"pdf_field":""},{"help":"Name and designation of authorized signatory","type":"text","label":"Name & Designation","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexure A - Enrollment Data","fields":[{"help":"Name of the policyholder","type":"text","label":"Policyholder Name","options":[],"required":true,"pdf_field":""},{"help":"ID of primary insured member","type":"text","label":"Primary Insured Member ID","options":[],"required":true,"pdf_field":""},{"help":"Name of member or dependent","type":"text","label":"Member/Dependent Name","options":[],"required":true,"pdf_field":""},{"help":"Address of primary insured member","type":"text","label":"Insured Address of Primary Insured Member","options":[],"required":true,"pdf_field":""},{"help":"Age and DOB of member","type":"text","label":"Age & Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Relationship to primary insured","type":"text","label":"Relationship with Primary Insured Member","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Name of nominee if any","type":"text","label":"Nominee","options":[],"required":false,"pdf_field":""},{"help":"Provide ABHA number if available","type":"text","label":"Do you have ABHA No.? If Yes, please mention","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group health insurance proposals for groups, associations, or corporate bodies","attachments":["Required KYC documents as per Appendix 1","Annexure A - Enrollment Data"],"declarations":["Information provided will form the basis of the insurance policy and is subject to underwriting.","Policy will come into force only after full receipt of premium.","Notify in writing any change in occupation or health after proposal submission but before risk acceptance.","Consent to company seeking medical information from doctors or hospitals for underwriting or claims.","Consent to share information with government, regulatory authorities, and other insurance companies for underwriting and claims.","Policy may be voided if any untrue or incorrect statement or non-disclosure is found.","Consent to receive information from the company by physical or electronic means.","Premiums paid are from bonafide sources and not from illegal or unaccounted funds.","Consent to provide valid age, employment, membership proof or other documents as required.","Company may cancel contract if found guilty under Prevention of Money Laundering Act.","Consent to receive information from Central CKYC Registry via SMS/Email."],"dropped_labels":10},"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/2673-group-care-group-health-insurance-product-proposal-form"}