{"id":2726,"title":"ADVANTAGE TOP-UP PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/advantage-top-up/proposal-forms/advantage-top-up-proposal-form.pdf.pdf","sha256":"a016b3b50345745c6ce17a10d260bf3fbd3e459cc790652f2def8174fbcdf044","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for the Advantage Top-Up health insurance policy from Generali Central Insurance Company Limited. The proposer fills it to provide personal, health, nominee, and payment details for the insurance proposal.","notes":["Answer all mandatory fields marked with *.","Use block letters to fill the form.","Provide original documents where required.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","Provide ABHA number for all insured persons or create one online.","Attach policy copy to avail loyalty discount.","Fill Portability/Migration Request Form if applicable.","Activate E-mandate/E-NACH for instalment payments to ensure coverage.","Provide bank details for direct claim/refund payments if premium exceeds Rs. 10,000.","Digitally signed policy document will be sent by default; tick box if physical copy is desired.","Declarations must be signed by proposer; intermediary and witness declarations also required.","Section 41 of Insurance Act prohibits rebates; non-compliance may lead to penalty."],"title":"ADVANTAGE TOP-UP PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Desired Period of Insurance","fields":[{"help":"Enter the desired insurance coverage period","type":"text","label":"DESIRED PERIOD OF INSURANCE*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Details","fields":[{"help":"Enter full name with surname, first and middle names","type":"text","label":"Name of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Tick if present address is same as permanent","type":"checkbox","label":"Present Address: (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Provide landline and mobile numbers; mobile is mandatory","type":"text","label":"Contact Number*","options":[],"required":true,"pdf_field":""},{"help":"Enter landline number if available","type":"phone","label":"Landline:","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile*","options":[],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email Id*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth* DD / MM / YYYY","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Provide if available; else download form from website","type":"text","label":"e-IA Number (e-Insurance Account Number)","options":[],"required":false,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status*","options":["Married","Single","Widow/Widower","Divorced","Live-in Relationship"],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality*","options":[],"required":true,"pdf_field":""},{"help":"Select occupation or specify","type":"choice","label":"Occupation","options":["Service","Self Employed","Others: ______________________________"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Are you an existing Generali Central customer*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide if existing customer","type":"text","label":"Existing Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Provide if existing customer","type":"text","label":"Customer ID No.","options":[],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"If you are Differently Abled, please tick mark on the checkbox to provide confirmation. ☐","options":[],"required":false,"pdf_field":""},{"help":"Provide details if differently abled","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Provide percentage if differently abled","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Provide UDID number if differently abled","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Option","fields":[{"help":"Select one policy option","type":"choice","label":"POLICY OPTION* (please tick the policy option opted)","options":["Individual Plan (Self, Spouse/ Live-in partner, Dependent children up to the age of 25 years, 2 Dependent Parents can be covered in single proposal)","Family Floater Plan (Self, Spouse/ Live–in partner, up to 3 Dependent children up to the age of 25 years)","Family Floater Plan (Self, Spouse/ Live–in partner, 5 Dependent children up to the age of 25 years)"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Insured","fields":[{"help":"Enter final premium amount including GST","type":"amount","label":"Final Premium inclusive of GST*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Term","fields":[{"help":"Select policy term","type":"choice","label":"POLICY TERM* (please tick the term opted)","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Tick if opting for single premium payment with discount","type":"checkbox","label":"Please tick in case you opt for single premium payment, with long term discount for 2 years / 3 years policy period","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Loyalty Discount and Other Ongoing Health Insurance Information","fields":[{"help":"Select yes if you have a separate retail health insurance policy with Generali Central","type":"yes-no","label":"Do you want to get a Loyalty Discount*","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment and Bank Details","fields":[{"help":"Select instalment frequency if opting for instalments","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly"],"required":false,"pdf_field":""},{"help":"Tick to activate E-mandate/E-NACH; link sent to registered mobile","type":"checkbox","label":"E-mandate/E-NACH*","options":[],"required":false,"pdf_field":""},{"help":"Select payment option","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others (please specify)"],"required":false,"pdf_field":""},{"help":"Enter premium amount in numbers and words","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""},{"help":"Name of account holder for payment","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Cheque/DD/Pay order number","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Date of payment instrument","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Provide transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Fill bank details for claim/refund payments; mandatory if premium > ₹10,000","type":"text","label":"Bank Details (required for direct payment of claims/refunds): Name of account holder, Name of bank, Branch, Account no., Bank IFSC code, MICR, Account Type (Savings/Current/Others)","options":["Savings","Current","Others (please specify)"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Proposer’s Name","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Proposer’s Signature/ Thumb Impression","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Intermediary Declaration","fields":[{"help":"Name of insurance agent or intermediary","type":"text","label":"Intermediary Name","options":[],"required":true,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary Code","options":[],"required":true,"pdf_field":""},{"help":"Name of sales manager","type":"text","label":"Sales Manager Name","options":[],"required":false,"pdf_field":""},{"help":"Code of sales manager","type":"text","label":"Sales Manager Code","options":[],"required":false,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Vernacular Declaration","fields":[{"help":"Name of witness","type":"text","label":"Witness Name","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness Signature","options":[],"required":true,"pdf_field":""},{"help":"Name of intermediary or agent","type":"text","label":"Intermediary / Agent Name","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary or agent","type":"signature","label":"Intermediary / Agent Signature","options":[],"required":true,"pdf_field":""},{"help":"Name of Point of Sale Person","type":"text","label":"POSP Name","options":[],"required":false,"pdf_field":""},{"help":"Code of POSP","type":"text","label":"POSP Code","options":[],"required":false,"pdf_field":""},{"help":"PAN number of POSP","type":"text","label":"POSP PAN No.","options":[],"required":false,"pdf_field":""},{"help":"Date and place of declaration","type":"text","label":"Date and Place","options":[],"required":false,"pdf_field":""}],"filled_by":"intermediary or witness"},{"title":"Declaration by Authorized Representative or Person with Disability","fields":[{"help":"Name of authorized representative","type":"text","label":"Name of Authorized Representative","options":[],"required":false,"pdf_field":""},{"help":"Relationship of authorized representative to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":false,"pdf_field":""},{"help":"Address of authorized representative","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Contact number of authorized representative","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":false,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Advantage Top-Up health insurance policy","attachments":["Policy copy for loyalty discount","Request for authorisation form for NEFT claim/refund payments","Portability/Migration Request Form (if applicable)"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge and is authorized to propose for all insured persons.","The policy will commence only after full payment of premium and acceptance by the insurer.","The proposer will notify any change in occupation or health before risk acceptance.","The proposer consents to the insurer seeking medical and insurance information for underwriting and claims.","The proposer authorizes sharing of proposal and medical information with government and regulatory authorities.","The proposer declares no material information is withheld and understands policy may be void if untrue information is found.","The proposer consents to electronic communication from the insurer.","The proposer declares premium is paid from legal sources and consents to verification of source of funds.","The proposer confirms if premium is paid by a third party with insurable interest and refund will be processed accordingly.","The proposer declares applicable statuses such as HNI, NRI, Politically Exposed Person, etc., and provides registration number if NPO/NGO.","The proposer agrees information will be processed as per insurer's privacy policy.","The proposer consents to sharing ABHA number for medical history verification and claims facilitation.","The proposer consents to CKYC record verification and receiving related communications.","The proposer consents to Bima-ASBA facility for premium payment blocking and debiting.","The proposer optionally consents to use of personal information for quality and data analysis by third parties."],"dropped_labels":9},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"grievance","channel":"email","value":"GCIcare@generalicentral.com","label":"HELPLINE Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"atrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing the valid option from the helpline menu or writ","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-220-233 / 1860-500-3333 / 022-67837800","label":"HELPLINE","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"may have. You can escalate your concerns as per the\nescalation matrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Generali Central Insurance Company Ltd.\nUnit No. 301, 3rd Floor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.","label":"Corporate Grievance Redressal Officer (GRO) Address","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central Insurance Company Ltd.\nUnit No. 301, 3\nrd\nFloor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.\nLEVEL 3\nIf you are still not satisfied with the solution provided, you can email\nour CEO’s office.\nEMAIL OUR CEO’s OFF","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"GCIGRO@generalicentral.com","label":"Corporate Grievance Redressal Officer (GRO) Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"solution provided to you does not meet your expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mish","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-79001 97777","label":"Corporate Grievance Redressal Officer (GRO) Phone","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ur expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central In","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/generali-central-insurance/2726-advantage-top-up-proposal-form"}