{"id":2731,"title":"Criticare Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/criticare/proposal-forms/criticare-proposal-form.pdf.pdf","sha256":"7d86c2631a8cfe84bd015aa03c39745ed196cadc4624547a548d62de43a3a29d","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase Criticare health insurance from Generali Central Insurance Company Limited. The proposer fills it with personal, health, and nominee details to apply for insurance coverage.","notes":["Information marked with * is mandatory.","Use block letters to fill the form.","Attach original or valid copies of documents as proof where required.","Family floater policy covers up to 6 members: proposer, spouse, two dependent children, and two dependent parents.","ABHA number is required for all proposed insured persons; can be created at https://healthid.ndhm.gov.in/register.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","For premium payment in instalments, E-mandate/E-NACH activation is required for auto debit.","Digitally signed policy documents will be sent by email unless physical copy is requested.","Section for office use only is not to be filled by proposer.","Section 41 of Insurance Act prohibits rebates as inducement for insurance."],"title":"Criticare Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of the Insured/Proposer","fields":[{"help":"Select appropriate title and enter full name","type":"text","label":"PROPOSER DETAILS*: Name: Mr. Ms. M/s","options":["Mr.","Ms.","M/s"],"required":true,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"PERMANENT ADDRESS AND OTHER DETAILS: State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone no.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile no*.","options":[],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email id*","options":[],"required":true,"pdf_field":""},{"help":"Enter residential status","type":"text","label":"Residential Status","options":[],"required":null,"pdf_field":""},{"help":"Tick if present address is same as permanent address","type":"checkbox","label":"PRESENT ADDRESS (IF SAME AS ABOVE, PLEASE TICK)","options":["Same as permanent address"],"required":null,"pdf_field":""},{"help":"Enter state of present address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal PIN code of present address","type":"number","label":"Pin code","options":[],"required":null,"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 gender","type":"choice","label":"GENDER*","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter date of birth in dd/mm/yyyy format","type":"date","label":"DATE OF BIRTH*","options":[],"required":true,"pdf_field":""},{"help":"Tick one and attach copy","type":"choice","label":"PLEASE PROVIDE COPY OF ANY OF THE FOLLOWING AS PROOF OF AGE*","options":["Passport","Birth Certificate","Domicile Certificate","School or College Certificate","Others"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"MARITAL STATUS*","options":["Married","Single","Widow","Divorced"],"required":true,"pdf_field":""},{"help":"Enter educational qualification","type":"text","label":"EDUCATIONAL QUALIFICATION","options":[],"required":false,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"NATIONALITY*","options":[],"required":true,"pdf_field":""},{"help":"Enter residential status","type":"text","label":"RESIDENTIAL STATUS","options":[],"required":false,"pdf_field":""},{"help":"Select occupation type","type":"choice","label":"OCCUPATION*","options":["Service","Self Employed","Others"],"required":true,"pdf_field":""},{"help":"Enter name of organisation if applicable","type":"text","label":"ORGANISATION","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":["Differently Abled"],"required":false,"pdf_field":""},{"help":"Describe impairment type if applicable","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage of impairment","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter Unique Disability ID number if applicable","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Insured and Nominee","fields":[{"help":"Select policy type","type":"choice","label":"TYPE OF POLICY","options":["INDIVIDUAL","FAMILY FLOATER"],"required":null,"pdf_field":""},{"help":"Enter total premium amount","type":"amount","label":"Total Premium including Goods & Services Tax","options":[],"required":null,"pdf_field":""},{"help":"Fill appointee details if nominee is minor; total percentage must not exceed 100%","type":"table","label":"Appointee Details (Required only if the nominee is a minor) (Name, Age, Mobile No., Email ID, Present Address, Permanent Address, Relationship with Appointee, Specify the Percentage (%) of Claim amount payable to each nominee, Bank details of the Appointee including Account No, IFSC/MICR Code, Name of the Bank, Account Holder Name)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Lifestyle Details of Insured","fields":[{"help":"Answer yes or no for each insured person","type":"yes-no","label":"Is your occupation associated with any specific hazard (e.g. chemical factory, mines, explosives, radiation, corrosive chemicals etc)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured person","type":"yes-no","label":"Are you employed in the armed, Paramilitary or police forces?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured person","type":"yes-no","label":"Do you take part in activities or have hobbies that could be dangerous in any way?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"Do you consume or have ever consumed Tobacco, Alcohol or any Narcotic? (If yes, specify the details separately in the format below: Substance, Quantity/day, No of years since consuming)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Questions to be Answered by Female Insureds","fields":[{"help":"Answer if female insured","type":"yes-no","label":"Have you ever suffered /are you suffering from Gynecological Problems?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you ever undergone any investigation or treatment or received medical advice or consulted a physician for: (i) Any disease or disorder of the Cervix, Uterus, Ovary(ies) or Vagina, abnormal bleeding, Cancer or abnormal growth? (ii) Any disease or disorder of the Breast(s) such as Breast Lump/cyst, Fibrocystic disease, Nipple changes or discharge, cancer or growth? (iii) Have you undergone any mammogram or Pap smear? (If yes, then kindly provide date and the test result)","options":[],"required":true,"pdf_field":""}],"filled_by":"female proposer"},{"title":"Details of Medical Conditions if Any Health Question Answer is Yes","fields":[{"help":"Provide full medical details if any health question answered yes except question D.1","type":"text","label":"Details of the Treating/Family Doctor, Nature of ailment/Disease/Exact Diagnosis, First Date of Diagnosis, Details of current symptoms (onset, intensity and duration), List the current prescriptions or medicines taken for disorder, Is there any further consultation planned","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Insurance Information","fields":[{"help":"Provide details of other insurance policies if any","type":"table","label":"Details of any Critical illness Insurance cover held or applied for (Policy or Proposal No, Company Name, Year of Issue, Medical Conducted for the Policy (Y/N), Basic Sum Insured, Decision, Policy Status)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select premium payment frequency if opting for instalments","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":false,"pdf_field":""},{"help":"Tick to activate auto debit for instalments","type":"checkbox","label":"E-mandate/E-NACH","options":["E-mandate/E-NACH"],"required":false,"pdf_field":""},{"help":"Select payment mode","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others"],"required":false,"pdf_field":""},{"help":"Enter premium amount in rupees","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 bank account holder","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque/DD number if applicable","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Enter date of cheque/DD","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID for online payment","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Attach authorization form if premium is more than ₹10,000","type":"attachment","label":"Request for authorisation form attached with this Proposal Form to receive Claim / Refund Payments directly into your bank account through NEFT","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration & Authorization","fields":[{"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":""},{"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":""}],"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":"Agent to sign","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":"Witness to sign if applicable","type":"signature","label":"Witness Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"intermediary/agent"},{"title":"Declaration By Authorized Representative Or Person With Disability","fields":[{"help":"Enter authorized representative name","type":"text","label":"Name of Authorized Representative","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"Proposer to sign","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":"Witness to sign","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Health insurance proposal for individual or family floater policies","attachments":["Copy of proof of age (Passport, Birth Certificate, Domicile Certificate, School or College Certificate, Others)","Request for authorisation form to receive Claim / Refund Payments through NEFT"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and insurance information for underwriting and claims.","The company may share proposal information with government or regulatory authorities.","If any information is untrue or withheld, the policy may be void and premium forfeited.","The proposer consents to receive service information electronically including WhatsApp.","The information provided will be stored and used for insurance and servicing purposes.","The premium is paid from legally declared income and not from proceeds of crime.","The proposer confirms their status (HNI, NRI, Politically Exposed Person, etc.) as applicable.","The proposer agrees to processing of data as per the insurer's privacy policy.","If ABHA number is shared, consent is given to use it for medical history verification.","Consent is given to download and verify KYC records from Central KYC Registry.","Consent is given to block premium payment under BIMA-ASBA facility if opted.","Optional consent to use 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/2731-criticare-proposal-form"}