{"id":2745,"title":"Surakshit Loan Bima | Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/surakshit-loan-bima/proposal-forms/surakshit-loan-bima-proposal-form.pdf.pdf","sha256":"642b6d370370c661c8201a5598e42b84311ab00752f3c5902b518d1e63ade5b7","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Surakshit Loan Bima insurance to be filled by the applicant and co-applicant(s) seeking loan insurance coverage.","notes":["Fields marked with * are mandatory.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","If more than two applicants, Annexure I must be filled for each additional applicant.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Others (specify).","Use block letters to fill the form.","Attach authorization form for NEFT payments if premium is more than Rs. 10,000.","Digital policy document will be sent by email; tick box if physical copy is desired.","The form must be signed by proposer and witnessed if thumb impression is used.","Refer to the website for product prospectus and privacy policy."],"title":"Surakshit Loan Bima | Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Applicant and Co-Applicant Details","fields":[{"help":"","type":"text","label":"Name Sur Name First Name Middle Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Applicant","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Father’s /Husband Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Mobile number is mandatory","type":"phone","label":"Contact Number* (Landline) (M)*","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":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Present Address is Self-Owned Rented Co. Leased","options":["Self-Owned","Rented","Co. Leased"],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email Id*","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth and select gender","type":"date","label":"Date of Birth/ Gender Age : ……Yrs M / F","options":["M","F"],"required":false,"pdf_field":""},{"help":"Ayushman Bharat Health Account number","type":"text","label":"ABHA No^^","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status Married Single Widow/Widower Divorced","options":["Married","Single","Widow/Widower","Divorced"],"required":false,"pdf_field":""},{"help":"Number of children and others dependent","type":"number","label":"No. Of Dependents Children Others","options":[],"required":false,"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":"If not available, download form from website","type":"text","label":"e-IA Number (e-Insurance Account Number)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation Employed Self Employed (Full time / Part time)","options":["Employed","Self Employed"],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Are you Differently Abled, please tick mark on the checkbox to provide confirmation ☐","options":[],"required":false,"pdf_field":""},{"help":"If differently abled, specify type","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Education Qualification","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employer/ Business Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Type of Industry","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Designation & Nature of Job","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Monthly Income","options":[],"required":false,"pdf_field":""},{"help":"Specify source of other income","type":"amount","label":"Other Income (If Any) ₹ Source","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employer / Business Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Employer / Business Contact Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Years in Present Occupation","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Loan Account Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Loan Amount","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Loan Tenure","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Policy Tenure 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":false,"pdf_field":""}],"filled_by":"applicant and co-applicant"},{"title":"Insurance Period and Plan Details","fields":[{"help":"Enter start and end date of insurance","type":"date","label":"Period of insurance desired From: DD / MM / YYYY To: DD / MM / YYYY","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Plan Opted Plan A Plan B Plan C Plan D Plan E","options":["Plan A","Plan B","Plan C","Plan D","Plan E"],"required":false,"pdf_field":""},{"help":"Specify if Others","type":"choice","label":"Type of Loan Home Loan Personal Loan Auto Loan Others (Pls specify)","options":["Home Loan","Personal Loan","Auto Loan","Others"],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Loss of Job Opted Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Purpose of Loan","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Type of Property","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Property Ownership","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Loan Disbursement DD / MM / YYYY","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Location of Property","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Financier / Bank","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Nominee Details for Applicant","fields":[{"help":"Fill for up to 4 nominees","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Tick if same as above","type":"checkbox","label":"Present Address (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Nominee should preferably be immediate relative","type":"text","label":"Relationship with the Proposer","options":[],"required":false,"pdf_field":""},{"help":"Total must not exceed 100%","type":"number","label":"Specify the Percentage (%) of Claim amount payable to each nominee","options":[],"required":false,"pdf_field":""},{"help":"Fill if nominee is minor","type":"text","label":"Appointee Details (Required only if the nominee is a minor) Name Age Mobile No. Email ID Present Address (If same as above, please tick here) ☐ Permanent Address 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","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Nominee Details for Co-Applicant","fields":[{"help":"Fill for up to 4 nominees","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Tick if same as above","type":"checkbox","label":"Present Address (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Nominee should preferably be immediate relative","type":"text","label":"Relationship with the Proposer","options":[],"required":false,"pdf_field":""},{"help":"Total must not exceed 100%","type":"number","label":"Specify the Percentage (%) of Claim amount payable to each nominee","options":[],"required":false,"pdf_field":""},{"help":"Fill if nominee is minor","type":"text","label":"Appointee Details (Required only if the nominee is a minor) Name Age Mobile No. Email ID Present Address (If same as above, please tick here) ☐ Permanent Address 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","options":[],"required":false,"pdf_field":""}],"filled_by":"co-applicant"},{"title":"Medical Information","fields":[{"help":"Provide details if applicable","type":"table","label":"Other current or pending critical illness Insurance and/or personal accident details","columns":["Applicant/Co-Applicant","Sum Insured","Type of Policy","Insured since","Period of Insurance From","Period of Insurance To","Any Exclusions or Special Conditions applied","Claims made, if any"],"options":[],"required":false,"pdf_field":""}],"filled_by":"applicant and co-applicant"},{"title":"Payment Details","fields":[{"help":"Select payment mode","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","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":"","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":"","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Attach authorization form if applicable","type":"checkbox","label":"Request for authorisation form attached with this Proposal Form to receive Claim / Refund Payments through NEFT (necessary if premium > ₹ 10,000)","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Declarations and Authorizations","fields":[{"help":"","type":"text","label":"Proposer’s Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Proposer’s Signature/ Thumb Impression","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date DD / MM / YYYY","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Declaration by Authorized Representative or Person with Disability (Name, Relationship, Address, Contact No., Signature, Date, Witness Name and Signature, Place)","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Annexure I - Additional Co-Applicants Details","fields":[{"help":"","type":"text","label":"Name Sur Name First Name Middle Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Applicant","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Father’s /Husband Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address","options":[],"required":false,"pdf_field":""},{"help":"Mobile number mandatory","type":"phone","label":"Contact Number (Landline) (M)*","options":[],"required":true,"pdf_field":""},{"help":"Tick if same as above","type":"checkbox","label":"Present Address (If same as above, please tick here) ☐","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Present Address is Self-Owned Rented Co. Leased","options":["Self-Owned","Rented","Co. Leased"],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email Id","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth/ Gender Age : ……Yrs M / F","options":["M","F"],"required":false,"pdf_field":""},{"help":"Ayushman Bharat Health Account number","type":"text","label":"ABHA No^^","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status Married Single Widow/Widower Divorced","options":["Married","Single","Widow/Widower","Divorced"],"required":false,"pdf_field":""},{"help":"","type":"number","label":"No. Of Dependents Children Others","options":[],"required":false,"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":"","type":"choice","label":"Occupation Employed Self Employed (Full time / Part time)","options":["Employed","Self Employed"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Education Qualification","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employer/ Business Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Type of Industry","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Designation & Nature of Job","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Monthly Income","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Other Income (If Any) ₹ Source","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employer / Business Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Employer / Business Contact Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Years in Present Occupation","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Loan Amount","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""}],"filled_by":"co-applicants"}],"deadlines":[],"applies_to":"Loan insurance policies under Surakshit Loan Bima","attachments":["Request for authorisation form attached with this Proposal Form to receive Claim / Refund Payments"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","Consent is given to the company to seek medical and insurance information for underwriting and claims.","The company may share proposal and medical information with government and regulatory authorities.","If any information is found untrue, the policy shall be void and premium forfeited.","The premium is paid from legally declared income and not from proceeds of crime.","Consent to receive electronic communications and store data for servicing the policy.","Consent to share ABHA number for medical history verification and claims facilitation.","Consent to download CKYC record for KYC verification and receive related communications.","Optional consent to use personal information for quality and data analysis by third parties."],"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/2745-surakshit-loan-bima-proposal-form"}