{"id":2729,"title":"ACCIDENT SURAKSHA PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/personal-accident/proposal-forms/accident-suraksha-proposal-form.pdf.pdf","sha256":"5c08bdcff94454fe85b5e2f336c72240989cbcb2067a0f5131d2e4e74256afa0","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for Accident Suraksha insurance coverage for themselves and their family members.","notes":["Fields marked with * are mandatory.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","Use block letters to fill the form.","Provide original documents as required by the insurer.","Digital policy document will be sent by default; tick box if physical copy is desired.","E-mandate/E-NACH activation is required for auto debit of instalments.","Ensure total nominee percentage does not exceed 100%.","Attach request for authorization form for claim/refund payments if premium exceeds ₹ 10,000/-."],"title":"ACCIDENT SURAKSHA PROPOSAL FORM","submit":{"to":"Generali Central Insurance Company Limited","how":"post / in person / through intermediary or agent","address":"Registered Office: Unit No. 801 & 802, 8th Floor, Tower C, Embassy 247 Park, LBS Marg, Vikhroli (West), Mumbai – 400083"},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Specify the insurance coverage period","type":"text","label":"PERIOD OF INSURANCE*","options":[],"required":true,"pdf_field":""},{"help":"Enter surname, first name, and middle name","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":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Tick if permanent address is same as above","type":"checkbox","label":"Permanent address (If same as above, please tick here)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Provide landline and mobile number; 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":"Format DD / MM / YYYY","type":"date","label":"Date of Birth*","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":"If not available, download form from website and submit with proposal","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"],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality*","options":[],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Do you have a child / children? *","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Do you or your family members to be insured have any Loan from Financial organization? *","options":["Yes","No"],"required":true,"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":"Describe impairment type if applicable","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage if applicable","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter Unique Disability ID if applicable","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Insured","fields":[{"help":"Enter full name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Format DD / MM / YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Provide Ayushman Bharat Health Account number or create one online","type":"text","label":"ABHA No^^","options":[],"required":false,"pdf_field":""},{"help":"Describe any pre-existing conditions","type":"text","label":"Details of any pre-existing illness/ injury/ disability","options":[],"required":false,"pdf_field":""},{"help":"Provide detailed occupation description","type":"text","label":"Occupation. Describe job profile/ business activities in detail.","options":[],"required":true,"pdf_field":""},{"help":"Enter annual income if applicable","type":"amount","label":"Gross Annual Income (wherever applicable)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Tick if permanent address is same as present address","type":"checkbox","label":"Permanent Address (If same as above, please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter percentage share for each nominee","type":"number","label":"Specify the Percentage (%) of Claim amount payable to each nominee in the event of the policyholder’s death. The total percentage of contribution across all the nominee(s) must not exceed 100%","options":[],"required":true,"pdf_field":""},{"help":"Enter bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter name of bank account holder","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Appointee Details (if nominee is minor)","fields":[{"help":"Enter appointee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter appointee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Enter appointee's mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee's present address","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Tick if permanent address is same as present address","type":"checkbox","label":"Permanent Address (If same as above, please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship to appointee","type":"text","label":"Relationship with Appointee","options":[],"required":true,"pdf_field":""},{"help":"Enter percentage share for each appointee","type":"number","label":"Specify the Percentage (%) of Claim amount payable to each nominee in the event of the policyholder’s death. The total percentage of contribution across all the nominee(s) must not exceed 100%","options":[],"required":true,"pdf_field":""},{"help":"Enter bank IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter name of bank account holder","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Term and Coverage","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":"Fill sum insured amounts for each coverage and insured person; columns: Insured, Spouse, First Child, Second Child; rows: Accidental Death, Permanent Partial disablement, Permanent Total disablement, Temporary Total disablement, Child Education Support, Life Support Benefit, Accidental Medical Expenses, Accidental Hospitalisation, Hospital Cash Allowance, Loan Protector, Adaptation Allowance, Family Transportation Allowance, Broken Bones, Road Ambulance cover, Air Ambulance cover, Adventure Sports Benefit, Chauffer plan Benefit","type":"table","label":"Coverages and Premium* (Fill all Figures in INR)","options":[],"required":true,"pdf_field":""},{"help":"Enter gross premium amount","type":"amount","label":"Premium details: Gross Premium","options":[],"required":true,"pdf_field":""},{"help":"Enter discount amount if any","type":"amount","label":"Discount Applicable","options":[],"required":false,"pdf_field":""},{"help":"Enter loading amount if any","type":"amount","label":"Loading Applicable","options":[],"required":false,"pdf_field":""},{"help":"Enter GST amount","type":"amount","label":"Goods and Services tax","options":[],"required":true,"pdf_field":""},{"help":"Enter total premium amount","type":"amount","label":"Total Premium including Goods and Services tax","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select yes or no for Insured, Spouse, First Child, Second Child","type":"yes-no","label":"Do you have any other personal accident policy with Generali Central Insurance or any other insurance company? (for each insured person)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter policy number if applicable","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Enter insurer name if applicable","type":"text","label":"Name of the insurer","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Policy sum insured","options":[],"required":false,"pdf_field":""},{"help":"Enter insurance period","type":"text","label":"Period of Insurance","options":[],"required":false,"pdf_field":""},{"help":"Provide claim details if any","type":"text","label":"Claims Received/ Receivable","options":[],"required":false,"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","Annually"],"required":false,"pdf_field":""},{"help":"Tick to activate E-mandate/E-NACH for auto debit","type":"checkbox","label":"E-mandate/E-NACH*","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for E-mandate/E-NACH","type":"text","label":"Please provide the Bank Name","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"],"required":true,"pdf_field":""},{"help":"Enter premium amount in INR","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""},{"help":"Write premium amount in words","type":"text","label":"Amount in Words","options":[],"required":true,"pdf_field":""},{"help":"Enter name of account holder for payment instrument","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque/DD/instrument number","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Enter date of payment instrument","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for payment","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name for claims/refunds","type":"text","label":"Bank Details (required for direct payment of claims/ refunds in the account): Name of the account holder","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account no.","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"Bank IFSC code","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR","options":[],"required":false,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Others"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Authorizations","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 of proposer","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":"Declaration by Intermediary/Agent","fields":[{"help":"Enter 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":"Enter witness name if applicable","type":"text","label":"Witness Name","options":[],"required":false,"pdf_field":""},{"help":"Signature of witness if applicable","type":"signature","label":"Witness Signature","options":[],"required":false,"pdf_field":""},{"help":"Name of Point of Sales 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 intermediary declaration","type":"text","label":"Date and Place","options":[],"required":false,"pdf_field":""}],"filled_by":"intermediary/agent"},{"title":"Declaration by Authorized Representative or Person with Disability","fields":[{"help":"Enter name of authorized representative","type":"text","label":"Name of Authorized Representative","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter address of authorized representative","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter contact number","type":"phone","label":"Contact No","options":[],"required":true,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":true,"pdf_field":""},{"help":"Signature of proposer","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter witness name","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":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Accident Suraksha insurance policies","attachments":["Request for authorisation form to receive Claim / Refund Payments directly into bank account (if premium is more than ₹ 10,000/-)","Documents as per KYC requirements (implied from declarations)","Medical reports if applicable (implied from declarations)"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health before risk acceptance.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes sharing of proposal and medical information with government and regulatory authorities.","Non-disclosure or misrepresentation may render the policy void and premium forfeited.","The premium is paid from legally declared sources and not from proceeds of crime.","The proposer confirms their status (HNI, NRI, Politically Exposed Person, etc.) as applicable.","The proposer consents to sharing ABHA number for medical record verification if provided.","The proposer agrees to processing of data as per insurer's privacy policy.","The proposer consents to CKYC record verification.","The proposer may opt for Bima-ASBA facility to block premium amount in bank account.","Optional consent to use personal information for quality and data analysis by third parties."],"dropped_labels":5},"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/2729-accident-suraksha-proposal-form"}