{"id":2743,"title":"Sukshma Hospi-Cash (Micro-Insurance Product) Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/sukshma-hospicash-micro-insurance-product/proposal-forms/sukshma-hospi-cash-proposal-form.pdf.pdf","sha256":"4e2d6cd5f0e9a0693306f8a9f1ce007b8a689910e535110b160636d5dd0f1926","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families to apply for the Sukshma Hospi-Cash micro-insurance product. The proposer (applicant) fills it to provide personal, nominee, and product details for insurance coverage.","notes":["Information marked with * is mandatory","Use block letters and answer all questions carefully","Attach PAN copy if premium exceeds Rs. 1,00,000","Provide ABHA number for all insured persons or create one online","Nominee(s) should preferably be immediate relatives","Total claim percentage across nominees must not exceed 100%","Attach request for authorisation form for NEFT payments if premium > ₹10,000","Policy document will be sent digitally unless physical copy requested","Form must be signed by proposer or authorized representative with witness if thumb impression used","No rebate or inducement allowed as per Section 41 of Insurance Act, 1938"],"title":"Sukshma Hospi-Cash (Micro-Insurance Product) 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":"choice","label":"PROPOSER DETAILS*","options":["Mr.","Ms.","M/s","Mx."],"required":true,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","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":["tick if same as permanent address"],"required":false,"pdf_field":""},{"help":"Enter state of present address if different","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter PIN code of present address if different","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Tel No","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile no*","options":[],"required":true,"pdf_field":""},{"help":"Mandatory if premium is Rs. 50,000 or above in cash; attach PAN copy if premium exceeds Rs. 1,00,000","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"],"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*","options":[],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"NATIONALITY*","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"MARITAL STATUS*","options":["Married","Single","Divorced","Widow"],"required":true,"pdf_field":""},{"help":"Select occupation or specify if Others","type":"choice","label":"OCCUPATION*","options":["Service","Self-Employed","Others"],"required":true,"pdf_field":""},{"help":"Enter educational qualification","type":"text","label":"EDUCATIONAL QUALIFICATION","options":[],"required":false,"pdf_field":""},{"help":"Enter annual gross income","type":"amount","label":"ANNUAL GROSS INCOME","options":[],"required":false,"pdf_field":""},{"help":"Tick if differently abled and provide details below","type":"checkbox","label":"Are you Differently Abled, please tick mark on the checkbox to provide confirmation","options":["Yes"],"required":false,"pdf_field":""},{"help":"Describe type of impairment 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 UDID number if applicable","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Medical Information","fields":[{"help":"Tick yes or no; if yes, state how many months","type":"yes-no","label":"Please confirm, if any of the persons to be insured is pregnant (For Females Only)*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide for each person: Name, illness/injury in past 4 years, treatment details, date first treated, illness/injury prior to 4 years, treatment details, date first treated","type":"table","label":"Illness/injury details of the past 4 years & prior to 4 years","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no; if yes, give details","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance on your life ever been postponed, declined or accepted on special terms?*","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Product Details","fields":[{"help":"Select one","type":"choice","label":"Type of Policy*","options":["Individual","Family Floater (covering Self, Spouse and up to three dependent children up to 25 yrs)"],"required":true,"pdf_field":""},{"help":"Select hospitalization benefit plan duration","type":"choice","label":"Option","options":["5 days","10 days","15 days","20 days","25 days"],"required":true,"pdf_field":""},{"help":"Select plan","type":"choice","label":"Plan Opted","options":["A","B","C","D","E","F","G","H","I","J"],"required":true,"pdf_field":""},{"help":"Select daily cash amount","type":"choice","label":"Daily Cash Amount (Rs)","options":["100","200","300","400","500","600","700","800","900","1000"],"required":true,"pdf_field":""},{"help":"Select deductible period","type":"choice","label":"Deductible opted","options":["1 day","2 days","3 days"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select payment mode; specify if Others","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others"],"required":true,"pdf_field":""},{"help":"Enter premium amount in numbers","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 on payment instrument","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Cheque/DD/Pay Order number","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Date of payment instrument","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID if paid online","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":false,"pdf_field":""},{"help":"Bank account holder name","type":"text","label":"Name of the account holder","options":[],"required":false,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account no.","options":[],"required":false,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"Bank IFSC code","options":[],"required":false,"pdf_field":""},{"help":"MICR code","type":"text","label":"MICR","options":[],"required":false,"pdf_field":""},{"help":"Select account type; specify if Others","type":"choice","label":"Account Type","options":["Savings","Current","Others"],"required":false,"pdf_field":""},{"help":"Attach form to receive claim/refund payments via NEFT","type":"attachment","label":"Request for authorisation form","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"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’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"},{"title":"Declaration by Authorized Representative or Person with Disability","fields":[{"help":"Proposer signature","type":"signature","label":"Signature of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Name of authorized person","type":"text","label":"Name of Authorized Representative","options":[],"required":false,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":false,"pdf_field":""},{"help":"Address of authorized representative","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Phone number of authorized representative","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":["If proposal is not accepted, refund will be made within 30 days"],"applies_to":"Individual and Family Floater Sukshma Hospi-Cash micro-insurance product","attachments":["Request for authorisation form to receive Claim / Refund Payments via NEFT"],"declarations":["All information provided is true and complete to the best of the proposer’s knowledge","Policy is subject to underwriting and premium payment in full","Notify insurer of any change in occupation or health before risk acceptance","Consent to insurer seeking medical and insurance information for underwriting and claims","Consent to sharing proposal information with government and regulatory authorities","No undisclosed material information; policy void if untrue information found","Consent to receive service information electronically including WhatsApp","Information provided will be stored and used for insurance and servicing purposes","Premium paid from legal sources and insurer may verify source of funds","Proposer may be classified as HNI, NRI, Politically Exposed Person, Jeweller, NPO/NGO, Film Actor, Producer, or Others","Consent to processing of personal data as per insurer’s privacy policy","Consent to share ABHA number for medical history verification if provided","Consent to verification of KYC records from Central KYC Registry","Optional consent to use personal information for quality and data analysis"],"dropped_labels":10},"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/2743-sukshma-hospi-cash-micro-insurance-product-proposal-form"}