{"id":2746,"title":"Varishta 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/varishta-bima/proposal-forms/varishta-bima-proposal-form.pdf","sha256":"a415e7fb962d98ea96acf0f36b1d4124c3d1297b4844ea067f7b6005a202e6e7","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Varishta Bima insurance and is to be filled by the proposer who wishes to apply for the insurance policy.","notes":["Fields marked with * are mandatory.","Answer health questions with 'Yes' or 'No'.","Use original documents and reports as required.","Fill all details carefully to avoid rejection or cancellation.","Premium payment modes and instalment options must be selected carefully.","Digital policy documents will be sent by default; tick box if physical copy is desired.","For instalment payment, submit signed ACH/ECS/E-Mandate form.","Provide ABHA number for all insured persons or create one at https://healthid.ndhm.gov.in/register.","Nominee percentages must total 100%.","If nominee is minor, appointee details must be provided.","Use block letters where applicable."],"title":"Varishta Bima | Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter the desired insurance coverage period","type":"text","label":"PERIOD OF INSURANCE DESIRED*","options":[],"required":true,"pdf_field":""},{"help":"Enter surname, first name, and middle name","type":"text","label":"Name of the Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address*","options":[],"required":true,"pdf_field":""},{"help":"Tick if present address is same as permanent address","type":"checkbox","label":"Present Address address ((If same as above, please tick here)  ☐","options":["If same as above"],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter landline and mobile numbers; mobile is mandatory","type":"text","label":"Contact Number*","options":[],"required":true,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email Id*","options":[],"required":true,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Mandatory if premium exceeds Rs. 50,000 in cash or Rs. 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 marital status","type":"choice","label":"Marital Status*","options":["Married","Single","Widow/Widower","Divorced","Live-in relationship"],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality*","options":[],"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":"Select yes or no","type":"yes-no","label":"Are you an existing Generali Central customer*?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If existing customer, provide policy number","type":"text","label":"Existing Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If existing customer, provide customer ID","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":["Differently Abled"],"required":null,"pdf_field":""},{"help":"If differently abled, specify type","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Specify percentage","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":"Select one policy option","type":"choice","label":"POLICY OPTION* (please tick the policy option opted)","options":["Individual Plan","Family Floater Plan"],"required":true,"pdf_field":""},{"help":"Tick if opting for waiver (additional premium applies)","type":"checkbox","label":"Please tick for waiver of co-payment for claims other than pre-existing conditions","options":["Waiver of co-payment"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Insured","fields":[{"help":"Tick yes or no for each insured","type":"yes-no","label":"Medical reports (2 D Echo, Blood Pressure report, Glycosylated hemoglobin, blood urea & serum creatinine) within 15 days of the tests done submitted. Applicable for Sum Insured options of ₹ 2L, 3L, 4L and 5L","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Computation","fields":[{"help":"Enter final premium amount including GST","type":"amount","label":"Final Premium inclusive of GST","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill details for each appointee if nominee is minor","type":"table","label":"Appointee Details (Required only if the nominee is a minor) (Name, Age, Mobile No., Email ID, Present Address, Permanent Address, Relationship with Appointee, Percentage of Claim amount payable, Bank details including Account No., IFSC/MICR Code, Name of Bank, Account Holder Name)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Term and Payment Options","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":"Select instalment frequency if applicable","type":"choice","label":"Please tick any one option in case you want to opt for instalment option","options":["Monthly","Quarterly","Half Yearly"],"required":null,"pdf_field":""},{"help":"Tick if opting for single premium payment","type":"checkbox","label":"Please tick in case you opt for single premium payment, with long term discount for 2 years / 3 years policy period","options":["Single premium payment with long term discount"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select instalment frequency if applicable","type":"choice","label":"Instalment Frequency","options":["Monthly","Quarterly","Half Yearly","Annually"],"required":null,"pdf_field":""},{"help":"Tick if opting for E-mandate/E-NACH and provide bank name","type":"checkbox","label":"E-mandate/E-NACH*","options":["E-mandate/E-NACH"],"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 and amount in words","type":"amount","label":"Premium Amount","options":[],"required":null,"pdf_field":""},{"help":"Enter account holder name for payment","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque/DD/instrument number","type":"text","label":"Instrument Number","options":[],"required":null,"pdf_field":""},{"help":"Enter instrument date","type":"date","label":"Instrument Date","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction ID if online payment","type":"text","label":"Transaction ID (for online payments)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Fill bank details for claim/refund payments","type":"text","label":"Bank Details (required for direct payment of claims/refunds in the account): Name of the account holder, Name of the bank, Branch, Account no., Bank IFSC code, MICR, Account Type","options":["Savings","Current","Others (please specify)"],"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 proposer’s 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":null,"pdf_field":""},{"help":"Name of authorized representative","type":"text","label":"Name of Authorized Representative","options":[],"required":null,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Address of authorized representative","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of authorized representative","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Varishta Bima insurance policy proposal","attachments":["Duly filled and signed ACH/ECS/E-Mandate form (if opting for instalment payment)","Request for authorisation form to receive Claim / Refund Payments directly into bank account (if premium > ₹10,000)","Portability/Migration Request Form (if applicable)"],"declarations":["The proposer and insured must disclose all material facts truthfully and completely.","The policy will commence only after acceptance and full premium payment.","Notify insurer in writing 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 and medical information with government and regulatory authorities.","Information provided is true; non-disclosure may void policy and forfeit premium.","Consent to receive service information electronically including WhatsApp.","Information will be stored and used for insurance and servicing purposes.","Premium paid is from legal sources; insurer may verify source and reject proposal if suspicious.","Declare if proposer is HNI, NRI, Politically Exposed Person, Jeweller, NPO/NGO, Film Actor, Producer, or Others.","Consent to share ABHA number for accessing medical history confidentially for claims and services.","Information will be processed as per insurer's privacy policy.","Consent to insurer downloading CKYC record for KYC verification and receiving related communications.","Consent to Bima-ASBA facility to block premium amount in bank account upon proposal acceptance."],"dropped_labels":7},"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/2746-varishta-bima-proposal-form"}