{"id":2732,"title":"D.I.Y Health PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/d-i-y-health/proposal-forms/diy-health-proposal-form.pdf","sha256":"19ffa957c5092c4b2454d59c12c85e9409950344ac4964098789b674b3d9cf50","pages":12,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase the D.I.Y Health insurance policy from Generali Central Insurance Company Limited. The proposer fills it to provide personal, health, nominee, and payment details for underwriting and policy issuance.","notes":["Complete all sections in capitals and tick boxes where applicable.","Fields marked with an asterisk [*] are mandatory.","Failure to disclose material facts may lead to rejection or cancellation of policy.","Provide ABHA number for all insured persons or create one at https://healthid.ndhm.gov.in/register.","Use original age proof documents as listed.","For porting/migration, attach the relevant form.","E-mandate/E-NACH activation is required for auto-debit of instalments.","Policy documents will be sent digitally by default; tick if physical copy is required.","Use block letters and provide accurate contact details.","Premium payment must be from legal sources; insurer may request proof.","Signatures/thumb impressions must be provided where required.","Intermediary and witness declarations are required if applicable."],"title":"D.I.Y Health PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of Proposer","fields":[{"help":"Select title and enter full name in capitals","type":"text","label":"Proposer Name*","options":["Mr.","Mrs.","Ms.","Mx."],"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":"Enter age in years","type":"number","label":"Age (in years)","options":[],"required":null,"pdf_field":""},{"help":"Select one marital status","type":"choice","label":"Marital Status*","options":["Married","Single","Widow / Widower","Divorcee","Live-in relation"],"required":true,"pdf_field":""},{"help":"Select nationality or specify if others","type":"choice","label":"Nationality*","options":["Indian","NRI","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"E-mail ID*","options":[],"required":true,"pdf_field":""},{"help":"Select occupation or specify if others","type":"choice","label":"Occupation","options":["Self Employed","Salaried","Homemaker","Retired","Others (please specify)"],"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":"Enter full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter nearby landmark","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter city or town","type":"text","label":"City / Town","options":[],"required":null,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":null,"pdf_field":""},{"help":"Enter 6-digit postal code","type":"number","label":"Pin Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Tick if present address is same as permanent address, else fill details","type":"text","label":"Present Address* (If same as above, please tick here)","options":["Tick if same as permanent address"],"required":true,"pdf_field":""},{"help":"Enter nearby landmark","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter city or town","type":"text","label":"City / Town","options":[],"required":null,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":null,"pdf_field":""},{"help":"Enter 6-digit postal code","type":"number","label":"Pin Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone No.*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Are you an existing Generali Central Customer? *","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide existing policy number if applicable","type":"text","label":"If Yes, please provide, Existing Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Provide customer ID if applicable","type":"text","label":"Customer ID","options":[],"required":null,"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":null,"pdf_field":""},{"help":"Specify type of impairment if applicable","type":"text","label":"Type of Impairment","options":[],"required":null,"pdf_field":""},{"help":"Specify percentage of impairment if applicable","type":"number","label":"Percentage of Impairment","options":[],"required":null,"pdf_field":""},{"help":"Provide UDID number if applicable","type":"text","label":"UDID Number","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Persons Proposed to be Insured","fields":[{"help":"Select policy period","type":"choice","label":"Policy Period *","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Enter start date of policy","type":"date","label":"Proposed Policy Period* From","options":[],"required":true,"pdf_field":""},{"help":"Enter end date of policy","type":"date","label":"to","options":[],"required":true,"pdf_field":""},{"help":"Select cover type","type":"choice","label":"Cover Type*","options":["Individual","Family Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Select sum insured amount","type":"choice","label":"Sum Insured","options":["₹4,00,000","₹5,00,000","₹6,00,000","₹7,00,000","₹8,00,000","₹9,00,000","₹10,00,000","₹11,00,000","₹12,00,000","₹13,00,000","₹14,00,000","₹15,00,000"],"required":true,"pdf_field":""},{"help":"Select pre-hospitalization coverage days","type":"choice","label":"Pre-Hospitalization","options":["30 days","60 days","90 days"],"required":true,"pdf_field":""},{"help":"Select post-hospitalization coverage days","type":"choice","label":"Post Hospitalization","options":["60 days","90 days","120 days"],"required":true,"pdf_field":""},{"help":"Select waiting period for pre-existing diseases","type":"choice","label":"Pre-Existing Waiting Period","options":["1 year","2 years","3 years"],"required":true,"pdf_field":""},{"help":"Select waiting period for specified diseases","type":"choice","label":"Specified diseases - Waiting Period","options":["1 year","2 years"],"required":true,"pdf_field":""},{"help":"Select room rent capping option","type":"choice","label":"Room Rent","options":["1% of sum insured","No capping"],"required":true,"pdf_field":""},{"help":"ICU coverage is 2 times of the Room Rent selected or No Capping if selected","type":"text","label":"ICU","options":[],"required":null,"pdf_field":""},{"help":"Select OPD cover amount","type":"choice","label":"OPD Cover","options":["₹2,000","₹3,000","₹5,000","₹7,500","₹10,000"],"required":null,"pdf_field":""},{"help":"Select LASIK surgery cover amount","type":"choice","label":"LASIK Surgery","options":["₹30,000","₹50,000","₹75,000","₹100,000"],"required":null,"pdf_field":""},{"help":"Select yes or no for maternity benefit","type":"yes-no","label":"Maternity Benefit (Pre & Post natal expenses covered within maternity limits)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for road ambulance cover","type":"yes-no","label":"Road Ambulance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for emergency air ambulance cover","type":"yes-no","label":"Emergency Air Ambulance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for daily hospital cash benefit","type":"yes-no","label":"Daily Hospital Cash","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for convalescence benefit","type":"yes-no","label":"Convalescence Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for accompanying person benefit","type":"yes-no","label":"Accompanying Person (For patient less than 12 years)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for accidental death cover for primary member","type":"yes-no","label":"Accidental Death (Primary Member)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for accidental death cover for spouse","type":"yes-no","label":"Accidental Death (Spouse of Primary Member)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for critical illness booster","type":"yes-no","label":"Critical Illness Booster","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for cumulative bonus booster","type":"yes-no","label":"Cumulative Bonus Booster","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for accident booster","type":"yes-no","label":"Accident Booster","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for non-medical and consumables expenses cover","type":"yes-no","label":"Non-Medical & Consumables Expenses Cover","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for home health care cover","type":"yes-no","label":"Home Health Care","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no for alternative treatments cover","type":"yes-no","label":"Alternative Treatments","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no and percentage for voluntary co-payment","type":"choice","label":"Voluntary Co-Payment","options":["Yes","No","10%","20%","30%"],"required":null,"pdf_field":""},{"help":"Select yes or no and deductible amount for voluntary deductible","type":"choice","label":"Voluntary Deductible Option","options":["Yes","No","₹10,000","₹25,000","₹50,000","₹75,000","₹100,000"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Concurrent/Previous Insurance Policy Details","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Are you applying for porting / migration?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment and Bank Details","fields":[{"help":"Select premium payment frequency","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":null,"pdf_field":""},{"help":"Tick to opt for E-mandate/E-NACH and provide bank name","type":"checkbox","label":"E-mandate/E-NACH*","options":["E-mandate/E-NACH"],"required":null,"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":null,"pdf_field":""},{"help":"Enter premium amount in numbers and words","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter account holder name for payment","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque/DD/instrument number","type":"text","label":"Instrument Number","options":[],"required":null,"pdf_field":""},{"help":"Enter instrument date","type":"date","label":"Instrument Date","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Others (please specify)"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details of Proposer","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Do you have an EIA","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if applicable","type":"text","label":"If Yes, please quote the EIA number","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If No, do you wish to apply for EIA","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide preferred insurance repository if applying","type":"text","label":"If applied, please mention your preferred Insurance Repository","options":[],"required":null,"pdf_field":""},{"help":"Enter email ID registered with insurance repository","type":"email","label":"Email ID (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / Thumb Impression of Proposer","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":""},{"help":"Print name of proposer","type":"text","label":"Name of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable categories","type":"checkbox","label":"I am (please tick all that are applicable)","options":["HNI","NRI","Politically Exposed Person","Jeweller","NPO/NGO","Film Actor","Producer","Others"],"required":null,"pdf_field":""},{"help":"Provide registration number if applicable","type":"text","label":"If you are an NPO/NGO, please provide Niti Aayog – Darpan Portal registration number","options":[],"required":null,"pdf_field":""},{"help":"Tick to consent for BIMA ASBA facility","type":"checkbox","label":"Bima – ASBA Declaration","options":["Consent to block premium under BIMA ASBA facility"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Intermediary Declaration","fields":[{"help":"Agent/intermediary signs here","type":"signature","label":"Signature of Agent / Intermediary","options":[],"required":true,"pdf_field":""},{"help":"Print POSP name","type":"text","label":"POSP Name","options":[],"required":null,"pdf_field":""},{"help":"Enter POSP code","type":"text","label":"POSP Code","options":[],"required":null,"pdf_field":""},{"help":"Enter POSP PAN number","type":"text","label":"POSP PAN No.","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Vernacular Declaration","fields":[{"help":"Print witness name","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Witness signs here","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"witness"},{"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":null,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter contact number","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Authorized representative signs here","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":null,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Print witness name","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Witness signs here","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"D.I.Y Health insurance policy proposal","attachments":["Age proof document for each person proposed to be insured (e.g. Passport, PAN Card, Driving License, School/College leaving certificate, Letter from recognized public authority)","Portability / migration form if applying for porting/migration","Request for authorisation form for NEFT claim/refund payments if premium is more than ₹10,000"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge and is authorized to propose for all persons insured.","The policy will come into force 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 insurer may seek medical and other information for underwriting and claims.","The insurer may share proposal and medical information with government and regulatory authorities.","The proposer confirms no undisclosed material information; false information may void the policy and forfeit premium.","The proposer consents to receive service information electronically and consents to data storage and use as per privacy policy.","The premium is paid from legally declared sources and the insurer may verify source of funds.","The proposer confirms who paid the premium and requests refunds to be processed to proposer’s bank account.","The proposer declares applicable categories such as HNI, NRI, PEP, NPO/NGO, etc.","The proposer consents to processing of information as per insurer’s privacy policy.","If ABHA number is shared, consent is given for use of medical history for claims and insurance services.","The proposer consents to CKYC record verification and receiving related communications.","Consent to block premium under BIMA ASBA facility if opted.","The intermediary declares having explained product features and proposal contents to the proposer.","The vernacular witness declares having explained the product and form contents to the proposer if thumb impression is used.","Authorized representative declaration authorizes acting on behalf of proposer for all insurance matters."],"dropped_labels":7},"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/2732-d-i-y-health-proposal-form"}