{"id":2744,"title":"HOSPICASH PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/hospicash/proposal-forms/hospicash-proposal-form.pdf","sha256":"d66821e05bcb2d763359c1c1c5f9cc0051e4becb1f341dacf6d46f3da9df8302","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (policyholder) to apply for Hospicash insurance coverage by Generali Central Insurance Company Limited.","notes":["Information marked with * is mandatory.","Use block letters to fill the form.","Provide original documents where required.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","Provide ABHA number for all insured persons or create one at https://healthid.ndhm.gov.in/register.","Attach request for NEFT authorization form if premium is more than ₹ 10,000/-.","Digitally signed policy document will be sent by email unless physical copy is requested.","Ensure total percentage allocation to nominees does not exceed 100%.","If nominee is minor, provide appointee details.","E-mandate/E-NACH activation is required for auto-debit of instalments.","Intermediary must explain product features and suitability to proposer.","Vernacular declaration required if proposer signs in thumb impression or non-English language."],"title":"HOSPICASH PROPOSAL FORM","submit":{"to":"Generali Central Insurance Company Limited","how":"post / e-mail / upload via company website or as instructed by intermediary","address":"Registered Office: Unit No. 801 & 802, 8th Floor, Tower C, Embassy 247 Park, LBS Marg, Vikhroli (West), Mumbai – 400083; Email ID: gcicare@generalicentral.com"},"purpose":"proposal","sections":[{"title":"Details of the Insured/Proposer","fields":[{"help":"Select title and enter full name","type":"text","label":"PROPOSER DETAILS*: Name: ☐ Mr. ☐ Ms. ☐ M/s","options":["Mr.","Ms.","M/s"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"GENDER*: ☐ Male  ☐ Female  ☐ Third Gender","options":["Male","Female","Third Gender"],"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*","options":[],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"NATIONALITY*","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"MARITAL STATUS*: ☐ Married ☐ Single ☐ Widow ☐ Divorced","options":["Married","Single","Widow","Divorced"],"required":true,"pdf_field":""},{"help":"If Others, specify","type":"choice","label":"OCCUPATION*: ☐ Salaried ☐ Self Employed ☐ Others:","options":["Salaried","Self Employed","Others"],"required":true,"pdf_field":""},{"help":"Enter highest educational qualification","type":"text","label":"EDUCATIONAL QUALIFICATION","options":[],"required":false,"pdf_field":""},{"help":"Enter monthly income in numbers","type":"number","label":"MONTHLY INCOME*","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you an existing Generali Central Customer? *: ☐  Yes     ☐  No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide existing policy number if applicable","type":"text","label":"If yes, existing policy no.","options":[],"required":false,"pdf_field":""},{"help":"Provide customer ID if applicable","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 type of impairment if applicable","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Provide percentage if applicable","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Provide UDID number if applicable","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""},{"help":"Enter full permanent address including State and Pin code","type":"text","label":"PERMANENT ADDRESS","options":[],"required":false,"pdf_field":""},{"help":"Enter present address or tick if same as permanent","type":"text","label":"PRESENT ADDRESS (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile no*","options":[],"required":true,"pdf_field":""},{"help":"Enter fax number if any","type":"text","label":"Fax no","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id*","options":[],"required":true,"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":false,"pdf_field":""},{"help":"Provide if available; else download form from website","type":"text","label":"e-IA Number (e-Insurance Account Number)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Insured Members","fields":[{"help":"Enter name of each insured member","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender for each insured member","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter date of birth for each insured member","type":"date","label":"Date of Birth (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"Select marital status for each insured member","type":"choice","label":"Marital Status","options":["Married","Single","Widow","Divorced"],"required":false,"pdf_field":""},{"help":"Provide Ayushman Bharat Health Account number for each insured","type":"text","label":"ABHA No^^","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"Enter height in centimeters","type":"number","label":"Height (Cm)","options":[],"required":false,"pdf_field":""},{"help":"Enter weight in kilograms","type":"number","label":"Weight (Kg)","options":[],"required":false,"pdf_field":""},{"help":"Internal use or identification number","type":"text","label":"IO No","options":[],"required":false,"pdf_field":""},{"help":"Application number if any","type":"text","label":"App No","options":[],"required":false,"pdf_field":""},{"help":"Client code if applicable","type":"text","label":"Client Code","options":[],"required":false,"pdf_field":""},{"help":"Receipt number if applicable","type":"text","label":"Receipt No","options":[],"required":false,"pdf_field":""},{"help":"Payer identification number if applicable","type":"text","label":"Payer ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Pregnancy Details","fields":[{"help":"","type":"yes-no","label":"Please confirm, if any of the persons to be insured is pregnant (For Females Only) *: ☐ Yes ☐ No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter number of months pregnant","type":"number","label":"If yes please state how many months?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you or any of the family members to be covered have / had any health complaints / met with any accident in the past 4 years and have been taking treatment / hospitalization? * ☐ Yes ☐ No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill illness/injury details for past 4 years and prior to 4 years with treatment details and dates","type":"table","label":"Has any of the persons to be insured suffer from / or investigated for any of the following? * (Disorder of heart, circulatory system, chest pain, high blood pressure, stroke, asthma, respiratory conditions, cancer, tumor, lump, diabetes, hepatitis, urinary tract or kidney disorders, blood disorder, mental or psychiatric conditions, brain or nervous system diseases, epilepsy, slipped disc, back ache, congenital/birth defects, AIDS or HIV). If yes, indicate in the table below.","options":[],"required":true,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Has any proposal for life, critical illness or health related insurance on your life ever been postponed, declined or accepted on special terms?* ☐ Yes ☐ No","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee present address","type":"text","label":"Present Address","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee permanent address or tick if same as present","type":"text","label":"Permanent Address (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the Proposer","options":[],"required":false,"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 must not exceed 100%","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account details for claim/refund payments","type":"text","label":"Bank details of the nominee","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter account holder name","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Appointee Details (if nominee is minor)","fields":[{"help":"Enter appointee name","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee age","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee present address","type":"text","label":"Present Address","options":[],"required":false,"pdf_field":""},{"help":"Enter appointee permanent address or tick if same as present","type":"text","label":"Permanent Address (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with Appointee","options":[],"required":false,"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 must not exceed 100%","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account details for claim/refund payments","type":"text","label":"Bank details of the Appointee","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC or MICR code","type":"text","label":"IFSC/MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter account holder name","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Product Details","fields":[{"help":"Select one","type":"choice","label":"Type of Policy: ☐ Individual ☐ Family Floater","options":["Individual","Family Floater"],"required":true,"pdf_field":""},{"help":"Select hospitalization benefit option","type":"choice","label":"Option (30 days / 60 days / 90 days / 180 days)","options":["30 days","60 days","90 days","180 days"],"required":true,"pdf_field":""},{"help":"Select one hospitalization benefit plan","type":"choice","label":"Hospitalisation benefit (A/ B/ C/ D)","options":["A","B","C","D"],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium","options":[],"required":true,"pdf_field":""},{"help":"Select if opting for instalment payment","type":"choice","label":"Instalment Frequency: Monthly ☐ Quarterly ☐ Half Yearly ☐ Annually ☐","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":false,"pdf_field":""},{"help":"Tick to activate E-mandate/E-NACH and provide bank name","type":"checkbox","label":"E-mandate/E-NACH* ☐ Please provide the Bank Name:","options":[],"required":false,"pdf_field":""},{"help":"Select payment option; specify if Others","type":"choice","label":"Payment Option: Cheque ☐ Demand Draft ☐ Fund Transfer ☐ Pay Order ☐ Debit Card ☐ Credit Card ☐ Others (please specify) ☐","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others"],"required":true,"pdf_field":""},{"help":"Enter premium amount in numbers and words","type":"amount","label":"Premium Amount: ₹________ Amount in Words:","options":[],"required":true,"pdf_field":""},{"help":"Enter name of account holder for payment","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque/DD/instrument number if applicable","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Enter date of instrument","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for payment","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name for claims/refunds","type":"text","label":"Bank Details (required for direct payment of claims/refunds): Name of the account holder","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for claims/refunds","type":"text","label":"Name of the bank","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account no.","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"Bank IFSC code","options":[],"required":false,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR","options":[],"required":false,"pdf_field":""},{"help":"Select account type; specify if Others","type":"choice","label":"Account Type: ☐ Savings ☐ Current ☐ Others (please specify)","options":["Savings","Current","Others"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Enter date of signing","type":"date","label":"Date: DD / MM / YYYY","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter proposer 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":""},{"help":"Tick Yes or No","type":"yes-no","label":"Optional Declaration: I/We hereby give my/our consent to the Company to use my/our personal information for quality and data analysis purpose which may be carried out by an empaneled third party vendors ☐ Yes / ☐ No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Intermediary Declaration","fields":[{"help":"Enter intermediary name","type":"text","label":"Intermediary Name","options":[],"required":true,"pdf_field":""},{"help":"Enter intermediary code","type":"text","label":"Intermediary Code","options":[],"required":true,"pdf_field":""},{"help":"Enter sales manager name","type":"text","label":"Sales Manager Name","options":[],"required":false,"pdf_field":""},{"help":"Enter sales manager code","type":"text","label":"Sales Manager Code","options":[],"required":false,"pdf_field":""},{"help":"Signature of intermediary or agent","type":"signature","label":"Intermediary / Agent Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Vernacular Declaration","fields":[{"help":"Enter witness name","type":"text","label":"Witness Name","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date and place of witnessing","type":"text","label":"Date and Place","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter address of authorized representative","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter contact number","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":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter witness name","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":"Hospicash insurance policy proposal","attachments":["Request for authorisation form to receive Claim / Refund Payments through NEFT (if premium is more than ₹ 10,000/-)","Medical reports or documents if health complaints or hospitalization in past 4 years","Proof of identity and address as per KYC requirements"],"declarations":["The proposer declares all information given 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 other 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 understands insurer's rights under law.","The proposer agrees to receive electronic communications and consents to data processing as per privacy policy.","The proposer consents to sharing ABHA number for medical record verification if provided.","The proposer consents to CKYC record verification and receiving related communications.","The proposer may opt for Bima-ASBA facility to block premium amount in bank account upon proposal acceptance."],"dropped_labels":0},"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/2744-hospicash-proposal-form"}