{"id":2740,"title":"Health Elite | 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-elite/proposal-forms/health-elite-proposal-form.pdf.pdf","sha256":"cb48e78ba65356dae0427438ff5946c649d4280b60a5644168a39adeebe94584","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or groups proposing to purchase the Health Elite insurance policy from Generali Central Insurance Company Limited. The proposer fills it to provide personal, health, and policy details for underwriting.","notes":["Information marked with * is mandatory.","Use block letters to fill the form.","PAN is mandatory for cash premiums of ₹50,000 and above; PAN copy mandatory if premium exceeds ₹1,00,000 in any mode.","Provide ABHA number for all insured persons or create one at https://healthid.ndhm.gov.in/register.","For Family Floater cover, do not fill sum insured and premium computation columns for individual members.","Attach age proof documents for each insured person.","Fill and attach portability/migration request form if opting for portability or migration.","Premium payment via E-mandate/E-NACH requires activation via link sent to registered mobile number.","Digitally signed policy document will be sent by default; tick box if physical copy is desired.","Declarations must be signed by proposer; thumb impression requires witness signature.","Intermediary must declare product explanation and suitability to proposer.","Authorized representative form must be filled if proposer authorizes another person to act on their behalf."],"title":"Health Elite | Proposal Form","submit":{"to":"Generali Central Insurance Company Limited","how":"post / in person / as per intermediary instructions","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":"","type":"text","label":"IO No/ Win No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"App No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Client Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Receipt No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Payer ID","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of insurance coverage","type":"date","label":"Period of insurance desired: from: DD / MM / YYYY to DD / MM / YYYY","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Name","options":["Mr.","Ms.","M/s"],"required":true,"pdf_field":""},{"help":"Full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"State of permanent address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal code of permanent address","type":"number","label":"Pin code","options":[],"required":true,"pdf_field":""},{"help":"Tick if present address is same as permanent","type":"checkbox","label":"Present Address:(If same as above, please tick here)","options":["tick if same as permanent address"],"required":null,"pdf_field":""},{"help":"State of present address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of present address","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel No","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile no*","options":[],"required":true,"pdf_field":""},{"help":"PAN mandatory if premium is ₹50,000 or above in cash; PAN copy mandatory if premium exceeds ₹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 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*","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age*","options":[],"required":true,"pdf_field":""},{"help":"Select nationality and specify if others","type":"choice","label":"Nationality*","options":["Indian","NRI","Others (Please specify)"],"required":true,"pdf_field":""},{"help":"Enter annual gross income in rupees","type":"amount","label":"Annual gross income (₹) *","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital status","options":["Married","Unmarried","Widow/Widower","Divorce","Live-In Relation"],"required":null,"pdf_field":""},{"help":"Select occupation and provide details if other","type":"choice","label":"Occupation*","options":["Service","Self Employed","Other"],"required":true,"pdf_field":""},{"help":"Describe occupation if 'Other' selected","type":"text","label":"Please provide details of occupation","options":[],"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":"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 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":["Differently Abled confirmation"],"required":null,"pdf_field":""},{"help":"Specify type of impairment if differently abled","type":"text","label":"Type of Impairment","options":[],"required":null,"pdf_field":""},{"help":"Specify percentage of impairment","type":"number","label":"Percentage of Impairment","options":[],"required":null,"pdf_field":""},{"help":"Provide UDID number if differently abled","type":"text","label":"UDID Number","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Options","fields":[{"help":"Select plan type","type":"choice","label":"Plan Type","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Select optional covers if desired","type":"checkbox","label":"Optional Covers","options":["Co-Pay Waiver","Treatment including USA and Canada"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Term and Family Definition","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 details for all members to be covered; provide ABHA number or create one at https://healthid.ndhm.gov.in/register","type":"table","label":"Details of persons to be insured*","options":["Sr. No","Name","Gender","Date of Birth","ABHA No","Relationship with Proposer","Height","Weight","Occupation","Premium computation individual or floater (for office use only)"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill appointee details if nominee is minor","type":"table","label":"Appointee Details (Required only if the nominee is a minor)","options":["Sr No","Name","Age","Mobile No.","Email ID","Present Address","Permanent Address (If same as above, please tick here)","Relationship with Appointee","Specify the Percentage (%) of Claim amount payable to each nominee","Bank details of the Appointee (Account No., IFSC/MICR Code, Name of the Bank, Account Holder Name)"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Section applicable for females only","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Please confirm if any of the persons to be insured is pregnant","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Age Proof Document Attachment","fields":[{"help":"Tick applicable age proof document","type":"checkbox","label":"Attach age proof document for each insured. Please tick whichever is applicable","options":["Passport","PAN Card","Driving license","School/college leaving certificate","Letter from recognized public authority","Others, please specify"],"required":true,"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":null,"pdf_field":""},{"help":"Tick to activate E-mandate/E-NACH; link will be sent to registered mobile","type":"checkbox","label":"E-mandate/E-NACH*","options":["E-mandate/E-NACH activation"],"required":null,"pdf_field":""},{"help":"Provide bank name for E-mandate/E-NACH","type":"text","label":"Please provide the Bank Name","options":[],"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 rupees","type":"amount","label":"Premium Amount","options":[],"required":null,"pdf_field":""},{"help":"Write premium amount in words","type":"text","label":"Amount in Words","options":[],"required":null,"pdf_field":""},{"help":"Name of account holder for payment","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Cheque/DD/Pay Order 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":"Provide transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":null,"pdf_field":""},{"help":"Bank name for payment","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account holder name","type":"text","label":"Bank Details (required for direct payment of claims/refunds): Name of the account holder","options":[],"required":null,"pdf_field":""},{"help":"Bank name for claims/refunds","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","type":"choice","label":"Account Type","options":["Savings","Current","Others (please specify)"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","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":"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"},{"title":"Declaration by Intermediary/Agent","fields":[{"help":"Name of insurance agent or intermediary","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"Name of sales manager","type":"text","label":"Sales Manager Name","options":[],"required":null,"pdf_field":""},{"help":"Code of sales manager","type":"text","label":"Sales Manager Code","options":[],"required":null,"pdf_field":""},{"help":"Name of witness if proposer signed with thumb impression","type":"text","label":"Witness Name","options":[],"required":null,"pdf_field":""},{"help":"Name of intermediary or agent","type":"text","label":"Intermediary / Agent Name","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness Signature","options":[],"required":null,"pdf_field":""},{"help":"Signature of intermediary or agent","type":"signature","label":"Intermediary / Agent signature","options":[],"required":null,"pdf_field":""},{"help":"Name of Point of Sale Person","type":"text","label":"POSP Name","options":[],"required":null,"pdf_field":""},{"help":"Code of POSP","type":"text","label":"POSP Code","options":[],"required":null,"pdf_field":""},{"help":"PAN number of POSP","type":"text","label":"POSP PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Date and place of declaration","type":"text","label":"Date and Place","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Declaration By Authorized Representative Or Person With Disability","fields":[{"help":"Name of authorized representative","type":"text","label":"Name of Authorized Representative","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Address of authorized representative","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Contact number of authorized representative","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":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of Witness","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Date of witness signature","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":"Health Elite insurance policy proposals","attachments":["Age proof document for each insured (Passport, PAN Card, Driving license, School/college leaving certificate, Letter from recognized public authority, Others)","Request for authorisation form to receive Claim / Refund Payments if premium is more than ₹ 10,000/-","Portability/migration request form if opting for portability or migration"],"declarations":["The proposer declares that all statements and answers are 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 after submission and 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.","The proposer declares no undisclosed material information and consents to electronic communication from insurer.","The premium is paid from legally declared income and not from proceeds of crime; insurer may verify source of funds.","The proposer declares applicable status such as HNI, NRI, Politically Exposed Person, Jeweller, NPO/NGO, Film Actor, Producer, or Others.","The proposer agrees that information will be processed as per insurer's privacy policy.","The proposer consents to sharing ABHA number for medical history verification and claims facilitation.","The proposer consents to insurer verifying KYC records from Central KYC Records Registry.","The proposer consents to Bima-ASBA facility for blocking premium payment from bank account if opted."],"dropped_labels":8},"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/2740-health-elite-proposal-form"}