{"id":2733,"title":"HEALTH 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/health-suraksha/proposal-forms/health-suraksha-proposal-form.pdf.pdf","sha256":"683b204e702e982629e70a49587f834a3a6667ded434aed68371d541d562b18f","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Health Suraksha insurance policy by Generali Central Insurance Company Limited. The proposer fills it to provide personal, family, health, and nominee details for insurance coverage.","notes":["Fields marked with * are mandatory.","Use block letters to fill the form.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1,00,000 in any mode.","Provide ABHA number for all insured persons or create one at https://healthid.ndhm.gov.in/register.","Sum insured of ₹50,000, ₹100,000, ₹150,000 is available only for children up to age 25 years.","Premium for floater plans is based on the age of the eldest member.","Attach policy copy to avail loyalty discount.","Fill Portability/Migration Request Form if applicable.","Activate E-mandate/E-NACH for auto debit of instalments; list of eligible banks available at NPCI website.","Provide bank details for direct claim/refund payments; mandatory if premium exceeds ₹10,000.","Digital policy documents will be sent by default; tick if physical copy is required.","Intermediary must explain product features and proposal form contents to proposer.","If proposer signs with thumb impression, vernacular declaration by witness is required."],"title":"HEALTH SURAKSHA 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 including surname, first and middle names","type":"text","label":"Name of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter full permanent address including state and pin code","type":"text","label":"Full Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Tick if present address is same as permanent address","type":"checkbox","label":"Present Address: (If same as above, please tick here) ☐","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 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. 1,00,000 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","Live-in Relationship"],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality*","options":[],"required":true,"pdf_field":""},{"help":"Select occupation; if Others, 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":[],"required":true,"pdf_field":""},{"help":"If existing customer, provide policy number","type":"text","label":"Existing Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If existing customer, provide customer ID","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":"Family Doctor Details","fields":[{"help":"Enter full name including surname, first and middle names","type":"text","label":"Name of the Dr*","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including state and pin code","type":"text","label":"Full Address*","options":[],"required":true,"pdf_field":""},{"help":"Provide landline and mobile numbers","type":"text","label":"Contact Number","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email Id","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Term","fields":[{"help":"Select policy term","type":"choice","label":"Policy term* (please tick the term opted): 1 Year, 2 Years, 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Tick if opting for single premium payment with long term 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":"Health Questions","fields":[{"help":"Confirm pregnancy status if applicable","type":"yes-no","label":"Please confirm if any of the persons to be insured is pregnant (For females only)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Loyalty Discount and Other Health Insurance Policies","fields":[{"help":"Select if you want loyalty discount","type":"yes-no","label":"Do you want to get a Loyalty Discount* (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of other health insurance policies for each insured person","type":"table","label":"Details of Other Concurrent Health Insurance Policies including Insured Person, Do you have other health insurance (Yes/No), Policy No, Name of insurer, Policy sum insured, Period of Insurance, Claims Received/Receivable","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment and Bank Details","fields":[{"help":"Select instalment frequency if opting for instalment payment","type":"choice","label":"Instalment Frequency: Monthly, Quarterly, Half Yearly","options":["Monthly","Quarterly","Half Yearly"],"required":false,"pdf_field":""},{"help":"Select payment option","type":"choice","label":"Payment Option: Cheque, Demand Draft, Fund Transfer, Pay Order, Debit Card, Credit Card, Others (specify)","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":"Name of bank account holder for payment","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Cheque/DD/Pay order number if applicable","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Date of 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":"Name of bank for payment","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"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":""},{"help":"Print proposer’s 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"}],"deadlines":[],"applies_to":"Health Suraksha insurance policy proposals","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.","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 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 confirms premium is paid from legal sources and consents to verification.","The proposer agrees to receive service information electronically and consents to data storage and use as per privacy policy.","The proposer consents to sharing ABHA number for medical record access and claims facilitation.","The proposer consents to CKYC record verification and receiving related communications.","The proposer may opt for Bima-ASBA facility to block premium payment from bank account upon proposal acceptance.","The proposer acknowledges reading and understanding the prospectus and product features explained by the intermediary."],"dropped_labels":14},"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/2733-health-suraksha-proposal-form"}