{"id":2738,"title":"HIV & Disability Suraksha, Generali Central Insurance Company Limited: Proposal form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/hiv-disability-suraksha-generali-central-insurance-company-limited/proposal-forms/hiv-and-disability-suraksha-proposal-form.pdf","sha256":"7c412bc67f05c26451512a8c0e8f49467ff541645f97693019f936c81e1d35da","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for applying for the HIV & Disability Suraksha insurance policy from Generali Central Insurance Company Limited. It is filled by the proposer who wishes to purchase the insurance.","notes":["Fields marked with * are mandatory.","Only Indian Nationals can be covered under this policy.","Use block letters to fill the form.","Premium payment modes and instalment options are available.","ABHA number is recommended for all insured persons; can be created online.","Attach the request for authorization form for direct claim/refund payments if premium exceeds ₹10,000.","The policy document will be sent digitally unless physical copy is requested.","Refer to the product prospectus available on the insurer's website for details.","Prohibition of rebates as per Section 41 of the Insurance Act, 1938 applies."],"title":"HIV & Disability Suraksha, Generali Central Insurance Company Limited: Proposal form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Contact Details","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"I. PROPOSER DETAILS","fields":[{"help":"Select appropriate title and enter full name","type":"text","label":"Proposer Name *","options":["Mr.","Mrs.","Ms.","Mx."],"required":true,"pdf_field":""},{"help":"Enter date 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","type":"choice","label":"Marital Status*","options":["Married","Single","Widow / Widower","Divorcee","Live-in relation"],"required":true,"pdf_field":""},{"help":"Select one and specify if Others","type":"choice","label":"Nationality*","options":["Indian","NRI","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Select one","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 one and 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. 1,00,000 in any mode","type":"text","label":"PAN Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Optional landmark near address","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / Town","options":[],"required":null,"pdf_field":""},{"help":"","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 10 digit mobile number","type":"phone","label":"Mobile No.*","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":"Optional landmark near present address","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / Town","options":[],"required":null,"pdf_field":""},{"help":"","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 10 digit mobile number","type":"phone","label":"Mobile No.*","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","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, existing policy no.","options":[],"required":null,"pdf_field":""},{"help":"Provide customer ID if applicable","type":"text","label":"Customer ID No.","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":[],"required":null,"pdf_field":""},{"help":"Describe impairment type, percentage and UDID number","type":"text","label":"If yes, kindly provide the below details Type of Impairment, Percentage of Impairment, UDID Number","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"II. POLICY/PLAN DETAILS","fields":[{"help":"Policy period is 1 year","type":"text","label":"Policy Period","options":["1 Year"],"required":null,"pdf_field":""},{"help":"Policy type is individual basis","type":"text","label":"Policy Type","options":["Individual Basis"],"required":null,"pdf_field":""},{"help":"Enter start date in DD/MM/YYYY","type":"date","label":"Proposed Policy Period From","options":[],"required":true,"pdf_field":""},{"help":"Select sum insured amount","type":"choice","label":"Sum Insured","options":["4,00,000","5,00,000"],"required":true,"pdf_field":""},{"help":"Select if waiver of co-payment is required","type":"choice","label":"Waiver of Co-Payment","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"III. PROPOSED INSURED DETAILS","fields":[{"help":"Tick if proposer is also insured","type":"checkbox","label":"Is Proposer also the Insured?","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of insured person","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"Provide Ayushman Bharat Health Account number or create one at https://healthid.ndhm.gov.in/register","type":"text","label":"ABHA No^^","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":""},{"help":"Enter height in centimeters","type":"number","label":"Height (cms)","options":[],"required":null,"pdf_field":""},{"help":"Enter weight in kilograms","type":"number","label":"Weight (Kgs)","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Married","Single","Widow / Widower","Divorcee","Live-in relation"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"IV. 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":null,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Present Address","options":[],"required":null,"pdf_field":""},{"help":"Tick if permanent address same as present","type":"checkbox","label":"Permanent Address (If same as above, please tick here) ☐","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship","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":"Provide Account No., IFSC/MICR Code, Name of the Bank, Account Holder Name","type":"table","label":"Bank details of the nominee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Appointee Details (Required only if the nominee is a 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":null,"pdf_field":""},{"help":"Enter appointee's email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter appointee's present address","type":"text","label":"Present Address","options":[],"required":null,"pdf_field":""},{"help":"Tick if permanent address same as present","type":"checkbox","label":"Permanent Address (If same as above, please tick here) ☐","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with Appointee","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":"Provide Account No., IFSC/MICR Code, Name of the Bank, Account Holder Name","type":"table","label":"Bank details of the Appointee","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"V. MEDICAL AND HEALTH INSURANCE","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Do You suffer from any pre-existing disability as per the listed condition mentioned in category 1 & 2 OR HIV/AIDS?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify disability category and duration","type":"text","label":"Please specify details and the no. of years you are suffering?","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Do you suffer from any pre-existing illness /injury other than Disability or HIV AIDS mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details and duration","type":"text","label":"If Yes, please specify details and the no. of years you are suffering?","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"VI. CONCURRENT/PREVIOUS INSURANCE POLICY DETAILS","fields":[{"help":"Select yes or no","type":"choice","label":"Are you having existing Health Policy of Generali Central or are you insured under any other Health Insurance Policy? YES ☐ NO ☐","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Do you have the same policy from any one or other insurer? YES ☐ NO ☐","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"VII. PREMIUM PAYMENT AND BANK DETAILS","fields":[{"help":"Select preferred instalment frequency","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":null,"pdf_field":""},{"help":"Tick to activate E-mandate/E-NACH for auto debit","type":"checkbox","label":"E-mandate/E-NACH*","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name for E-mandate","type":"text","label":"Please provide the Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Select payment mode and specify if Others","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 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","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Cheque/DD/Instrument number if applicable","type":"text","label":"Instrument Number","options":[],"required":null,"pdf_field":""},{"help":"Date of instrument","type":"date","label":"Instrument Date","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction ID for online payment","type":"text","label":"Transaction ID (for online payments)","options":[],"required":null,"pdf_field":""},{"help":"Name of bank for payment","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account details for claim/refund payments","type":"text","label":"Bank Details (required for direct payment of claims/ refunds in the account)","options":[],"required":null,"pdf_field":""},{"help":"Account holder name","type":"text","label":"Name of the account holder","options":[],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account no.","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"Bank IFSC code","options":[],"required":null,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"MICR","options":[],"required":null,"pdf_field":""},{"help":"Select account type and specify if Others","type":"choice","label":"Account Type","options":["Savings","Current","Others (please specify)"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"VIII. ELECTRONIC INSURANCE ACCOUNT DETAILS OF PROPOSER","fields":[{"help":"Select yes or no","type":"choice","label":"Do you have an EIA","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"If No, do you wish to apply for EIA","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide EIA number if available","type":"text","label":"If Yes, please quote the EIA number","options":[],"required":null,"pdf_field":""},{"help":"Provide preferred insurance repository","type":"text","label":"If applied, please mention your preferred Insurance Repository","options":[],"required":null,"pdf_field":""},{"help":"Enter registered email ID","type":"email","label":"Email Id (Registered with Insurance Repository)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"X. 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 Name","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / Thumb Impression of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"XI. DECLARATIONS BY INTERMEDIARY, WITNESS AND AUTHORIZED REPRESENTATIVE","fields":[{"help":"Fill if proposer authorizes a representative","type":"text","label":"Declaration by Authorized Representative or Person with Disability: Name, Signature, Relationship, Address, Contact No., Witness details","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary / witness / authorized representative"}],"deadlines":[],"applies_to":"Persons with Disability, Mental Illness and Person with HIV/AIDS as defined under relevant Indian laws","attachments":["Request for authorisation form attached with this Proposal Form to receive Claim / Refund Payments"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge.","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 after submission but before acceptance.","The insurer may seek medical and other information for underwriting and claim settlement.","The insurer may share proposal and medical information with government and regulatory authorities.","Non-disclosure of material facts may void the policy and forfeit premium.","The premium is paid from legally declared income and not from proceeds of crime.","The proposer consents to receive service-related information electronically.","The proposer consents to storage and use of data for insurance and servicing purposes.","The proposer consents to sharing ABHA number for medical record verification if provided.","The proposer consents to verification of KYC records from Central KYC Registry.","The proposer may authorize the insurer to block premium payment under Bima-ASBA facility.","The proposer 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/2738-hiv-and-disability-suraksha-generali-central-insurance-company-limited-proposal-"}