{"id":2760,"title":"STAND-ALONE COMPULSORY PERSONAL ACCIDENT COVER FOR OWNER DRIVER PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/motor-insurance/standalone-compulsory-personal-accident-cover-for-owner-driver/proposal-forms/standalone-compulsory-personal-accident.pdf","sha256":"8beaeb666c18780de8634d4c9c6e4bd27a219c252730c70bb8f137150b3d432e","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the proposer (owner driver) to apply for standalone compulsory personal accident insurance cover for their vehicle. The proposer fills this form to provide personal, vehicle, nominee, and payment details for the insurance policy.","notes":["Answer all questions; attach separate signed and dated sheet if additional space is needed.","Cover commences only after acceptance and receipt of premium.","Use block letters where applicable.","Company may reject proposal or terminate contract if proposer or associated persons are named in any recognized blacklist.","True to Go Green initiative, policy documents will be sent electronically unless physical copy is requested."],"title":"STAND-ALONE COMPULSORY PERSONAL ACCIDENT COVER FOR OWNER DRIVER PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name with title Mr. or Ms.","type":"text","label":"Name of the Proposer (in full): -        Mr.  Ms.","options":[],"required":true,"pdf_field":""},{"help":"Enter full present address including city, state, and pin code","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"City of present address","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of present address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Pin code of present address","type":"number","label":"Pin code","options":[],"required":true,"pdf_field":""},{"help":"Telephone number with STD code","type":"phone","label":"Telephone no","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter permanent address or leave blank if same as present address","type":"text","label":"Permanent address of the proposer (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"City of permanent address","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"State of permanent address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Pin code of permanent address","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Telephone number of permanent address","type":"phone","label":"Telephone no","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of permanent address","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Email ID of permanent address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Select preferred format for policy documents","type":"choice","label":"I want Private Car Insurance Policy and related information in:","options":["Physical Format","e-Format (electronic)"],"required":true,"pdf_field":""},{"help":"Enter e-Insurance Account number if applicable","type":"text","label":"e-IA number (e-Insurance Account number)","options":[],"required":false,"pdf_field":""},{"help":"Select one insurance repository if e-format chosen","type":"choice","label":"Choose Insurance Repository (for those selecting e-format):","options":["NSDL Data Management Ltd","CDSL Insurance Repository Ltd","Karvy Insurance Repository Ltd","CAMS Repository Services Ltd."],"required":false,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"CKYC No (Central Know Your Customer Registry No):","options":[],"required":false,"pdf_field":""},{"help":"Enter GSTIN if applicable; attach annexure if multiple","type":"text","label":"GSTIN: If applicable","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable categories","type":"checkbox","label":"I am (please tick all that are applicable)","options":["High Net Worth Individual/s","Non-Residential Indian/s","Politically Exposed Person","Non-Governmental Organisation","Non-Profit Organisation"],"required":false,"pdf_field":""},{"help":"Provide registration number if NGO/NPO","type":"text","label":"If you are an NGO/NPO, please provide Niti Ayog – Darpan Portal Registration Number:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If you are Differently Abled, please tick on the checkbox to provide confirmation.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If differently abled, specify type of impairment","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"If differently abled, specify percentage","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"If differently abled, provide UDID number","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vehicle Details","fields":[{"help":"Enter number of vehicles owned or registered in proposer's name","type":"number","label":"Number of Vehicle Own / Registered in the name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Vehicle make","type":"text","label":"Make","options":[],"required":true,"pdf_field":""},{"help":"Vehicle model","type":"text","label":"Model","options":[],"required":true,"pdf_field":""},{"help":"Class of vehicle registration","type":"text","label":"Class of Registration","options":[],"required":true,"pdf_field":""},{"help":"Year vehicle was manufactured","type":"number","label":"Year of Manufacturing","options":[],"required":true,"pdf_field":""},{"help":"Vehicle registration number","type":"text","label":"Registration Number","options":[],"required":true,"pdf_field":""},{"help":"Existing policy number if any","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Provide details if any other personal accident policy is active","type":"text","label":"Any other Personal Accident Insurance Policy in force. If Yes, please share the details","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"Name of Insurance Company","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Benefits covered under other policy","type":"text","label":"Benefit Covered","options":[],"required":false,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Period of Insurance From:","options":[],"required":false,"pdf_field":""},{"help":"End date of other policy","type":"date","label":"To:","options":[],"required":false,"pdf_field":""},{"help":"Nominee name and relationship under other policy","type":"text","label":"Nominee Details & Relationship","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Name of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Full address of nominee","type":"text","label":"Address of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Guardian details if nominee is minor","type":"text","label":"If Nominee is minor, please provide detail of guardian","options":[],"required":false,"pdf_field":""},{"help":"Nominee's date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Nominee's mobile number","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Nominee's email address","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Nominee's present address","type":"text","label":"Present address","options":[],"required":false,"pdf_field":""},{"help":"Nominee's permanent address or leave blank if same as present","type":"text","label":"Permanent address ((if left blank, will be construed as being same as Present Address))","options":[],"required":false,"pdf_field":""},{"help":"Nominee's bank account details","type":"text","label":"Bank Account Details of Nominee","options":[],"required":false,"pdf_field":""},{"help":"Bank account holder's name","type":"text","label":"Name of Account holder","options":[],"required":false,"pdf_field":""},{"help":"Bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFS Code","options":[],"required":false,"pdf_field":""},{"help":"Details of authorized person if nominee is minor","type":"text","label":"Authorized person details (in case nominee is a minor)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of payment","type":"choice","label":"Mode of Payment","options":[],"required":true,"pdf_field":""},{"help":"Provide payment reference or details","type":"text","label":"Payment Details","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Amount in (₹)","options":[],"required":true,"pdf_field":""},{"help":"Date when payment was made","type":"date","label":"Date of Payment (DD/MM/YY)","options":[],"required":true,"pdf_field":""},{"help":"Provide PAN if premium is 100,000 or more","type":"text","label":"PAN (If premium is 1 Lac and Above.)","options":[],"required":false,"pdf_field":""},{"help":"Provide GSTIN or attach annexure if multiple","type":"text","label":"GSTIN (If more than one GSTIN, kindly attach an annexure with details)","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details for refund or claim payments","type":"text","label":"Bank details of proposer for refund or claim purpose","options":[],"required":true,"pdf_field":""},{"help":"Name of bank account holder","type":"text","label":"Name of bank account holder (mention specifically, if different from name of policyholder)","options":[],"required":true,"pdf_field":""},{"help":"Bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFS Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by Proposer","fields":[{"help":"Sign the form; affix stamp if proposer is a juridical person","type":"signature","label":"Signature of the Proposer(s)","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":"Intermediary Use Only","fields":[{"help":"Name of intermediary","type":"text","label":"Name of Insurance Agent/POSP/Specified Person of the Corporate Agent/Authorized Person of the Broker/IMF","options":[],"required":true,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary’s Code","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary","type":"signature","label":"Intermediary’s Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"}],"deadlines":[],"applies_to":"Standalone compulsory personal accident cover for owner driver","attachments":["request for authorization form attached with this proposal form to receive claim/refund payments if any, directly into your bank account through NEFT if the premium amount is more than Rs.10,000/-","annexure with GSTIN details if more than one GSTIN","annexure with CKYC form if CKYC number not available"],"declarations":["All statements and information provided are complete and accurate with no relevant information withheld.","Misrepresentation or suppression of material facts may render the policy void and premium forfeited.","The proposer agrees to assist the insurer with records and information for anti-financial crime practices.","Premium is paid from legitimate sources and insurer may verify source of funds and reject or terminate policy if otherwise.","Consent to receive policy and service communications electronically and for processing of personal data.","Consent for insurer to access CKYC records for verification and communication.","Agreement to abide by insurer's Privacy Policy.","Insurer reserves right to reject or terminate contract if proposer or associated persons are on sanctions list.","KYC records are current and proposer will inform insurer of any changes."],"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/2760-stand-alone-compulsory-personal-accident-cover-for-owner-driver-proposal-form"}