{"id":2771,"title":"Travel Suraksha Select | Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/travel-insurance/travel-suraksha-select/proposal-forms/travel-suraksha-select-proposal-form.pdf.pdf","sha256":"8ec0028bcfdfc7de41250cae7f5283cbf38de5c37dafcd8a64714b448b66e79c","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for the Travel Suraksha Select insurance policy for themselves and other persons to be insured.","notes":["Information for fields marked with asterisk [*] is mandatory.","PAN is mandatory where premium exceeds Rs. 50,000 in cash or Rs. 1 lakh in any mode.","Please provide ABHA number for all proposed insured persons or create one at https://healthid.ndhm.gov.in/register.","Attach request for authorization form to receive claim/refund payments if premium is more than ₹10,000.","Policy document will be sent digitally by default; tick if physical copy is required.","Use block letters and provide complete and accurate information to avoid rejection or cancellation.","Original documents and proofs may be required for verification.","Section 41 of Insurance Act prohibits rebates as inducement for insurance.","For further details and prospectus, visit https://generalicentralinsurance.com."],"title":"Travel Suraksha Select | Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Insurance Period","fields":[{"help":"Specify the start and end date of the insurance coverage","type":"text","label":"Period of Insurance*","options":[],"required":true,"pdf_field":""},{"help":"Select title and enter full name","type":"text","label":"Name of the Proposer (in full)*","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"Permanent Address and Other Details: State","options":[],"required":null,"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":[],"required":false,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Tel No*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile no*","options":[],"required":true,"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":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","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status*","options":["Married","Single","Divorced","Widowed"],"required":true,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality*","options":[],"required":true,"pdf_field":""},{"help":"Select visa type","type":"choice","label":"Visa Type*","options":["Immigrant","Resident","Student","Travel"],"required":true,"pdf_field":""},{"help":"Select purpose of travel or specify if others","type":"choice","label":"Purpose of Travel","options":["Business","Employment/ Work","Leisure","Study","Others, please specify"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Details and Differently Abled Information","fields":[{"help":"Select one plan","type":"choice","label":"Plan Details* (Please tick on relevant box)","options":["Standard Select","Silver Select","Prime Care Select (Senior Citizen)"],"required":true,"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":"Describe type of impairment","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","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Travel and Insured Persons Details","fields":[{"help":"Enter departure date","type":"date","label":"Proposed date of departure from Republic of India*","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days for insurance coverage","type":"number","label":"No of days to be insured","options":[],"required":null,"pdf_field":""},{"help":"List countries to be visited","type":"text","label":"Please mention the list of countries that you intend to visit","options":[],"required":null,"pdf_field":""},{"help":"Fill details for each insured person: Name, Gender, Date of Birth, ABHA No, Nationality, Occupation, Relationship with Proposer, Passport Number, Name of illness/injury, Treatment/medication received/receiving","type":"table","label":"Details of persons proposed to be insured","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee and Appointee Details","fields":[{"help":"Provide for each appointee: Name, Age, Mobile No., Email ID, Present Address, Permanent Address (tick if same), Relationship with Appointee, Percentage of claim payable, Bank details (Account No., IFSC/MICR Code, Bank Name, Account Holder Name)","type":"table","label":"Appointee Details (Required only if the nominee is a minor)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Medical Details","fields":[{"help":"Indicate if any insured has listed diseases or conditions","type":"yes-no","label":"Does any person to be insured suffer or has suffered from any of the following?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter family doctor's name","type":"text","label":"Family doctor details: Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter premium amount in numbers","type":"amount","label":"Premium Amount","options":[],"required":null,"pdf_field":""},{"help":"Write premium amount in words","type":"text","label":"Amount in Words","options":[],"required":null,"pdf_field":""},{"help":"Enter name of account holder","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque/draft number","type":"text","label":"Instrument Number","options":[],"required":null,"pdf_field":""},{"help":"Enter date of instrument","type":"date","label":"Instrument Date","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction ID if paid online","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Others (please specify)"],"required":null,"pdf_field":""},{"help":"Enter cheque number if applicable","type":"text","label":"Premium paid by Cash/ Cheque No","options":[],"required":null,"pdf_field":""},{"help":"Enter date of payment","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name for payment","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount (INR)","options":[],"required":null,"pdf_field":""},{"help":"Write amount in words","type":"text","label":"Amount (in words)","options":[],"required":null,"pdf_field":""},{"help":"Provide GSTIN if applicable","type":"text","label":"GSTIN (If more than one GSTIN, kindly attach an annexure with details)","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN if premium is 1 lakh or above","type":"text","label":"PAN (if premium is 1 Lac and above.)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Document Delivery Preference","fields":[{"help":"Select if you want a physical copy of the policy document","type":"choice","label":"If you still wish for a physical copy, you may tick on this box Yes / No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Consent","fields":[{"help":"Enter full name of proposer","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":"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":""}],"filled_by":"proposer"},{"title":"Intermediary Declaration","fields":[{"help":"Enter intermediary's name","type":"text","label":"Intermediary Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date and place of declaration","type":"text","label":"Date and Place","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Vernacular Declaration (if proposer signs in thumb impression)","fields":[{"help":"Enter witness name","type":"text","label":"Witness Name","options":[],"required":true,"pdf_field":""},{"help":"Witness to sign","type":"signature","label":"Witness Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date and place","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 proposer name","type":"text","label":"Proposer Name","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"Enter date","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":"Witness to sign","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Travel Suraksha Select insurance policy","attachments":["Request for authorisation form to receive Claim / Refund Payments"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The proposer consents to the insurer seeking medical and insurance information for underwriting and claims.","The proposer authorizes sharing of proposal and medical information with government and regulatory authorities.","The proposer declares no undisclosed material information or illegal source of income related to the premium.","The proposer consents to electronic communication and data storage by the insurer.","The proposer agrees to verification of KYC records and receiving related communications.","The proposer may opt for Bima-ASBA facility to block premium payment from bank account.","Optional consent to use personal information for quality and data analysis.","Intermediary declares having explained product features and proposal contents to the proposer.","Authorized representative declaration allows acting on behalf of proposer for all insurance matters."],"dropped_labels":13},"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/2771-travel-suraksha-select-proposal-form"}