{"id":2773,"title":"Travel Suraksha Schengen Travel 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-Schengen-Travel/proposal-forms/travel-suraksha-schengen-travel-proposal-form.pdf.pdf","sha256":"4670d8a08d9ced961718369bce56debe6fff444d7484859a86257b1409e543fb","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Travel Suraksha Schengen Travel insurance policy. The proposer fills it to provide personal, travel, health, nominee, and payment details for underwriting and policy issuance.","notes":["Information for fields marked with asterisk [*] is mandatory.","Insurance contract requires utmost good faith; all material facts must be disclosed.","Incomplete or incorrect answers may lead to rejection or cancellation of policy.","Cover starts only after acceptance and premium payment.","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.","Use the request for authorisation form attached to receive claim/refund payments directly via NEFT if premium is more than ₹10,000.","Policy document will be sent digitally by default; tick box if physical copy is desired.","Use block letters and provide complete and accurate information.","Declarations must be signed by proposer; thumb impression requires witness and vernacular declaration.","Intermediary must declare product explanation and suitability to proposer.","Section 41 of Insurance Act prohibits rebates; violations may incur penalties."],"title":"Travel Suraksha Schengen Travel Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer and Travel Details","fields":[{"help":"Enter the insurance coverage period","type":"text","label":"Period of Insurance*","options":[],"required":true,"pdf_field":""},{"help":"Enter full name and select title","type":"text","label":"Name of the Proposer (in full) *   Mr.  Mrs.  Ms.","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Enter state of permanent address","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":"Tick if present address is same as permanent","type":"checkbox","label":"Present Address: (If same as above, please tick here) ☐ *","options":[],"required":true,"pdf_field":""},{"help":"Enter state of present address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code of present address","type":"number","label":"Pin code","options":[],"required":null,"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":"Tick if differently abled","type":"checkbox","label":"Are you Differently Abled, please tick mark on the checkbox to provide confirmation ☐","options":[],"required":false,"pdf_field":""},{"help":"Describe type of impairment","type":"text","label":"If yes, kindly provide below details Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage 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":""},{"help":"Select plan and trip duration","type":"choice","label":"Plan Opted for* (Please tick in relevant box)","options":["Individual","Family Floater","Single Trip","Standard Euro 30000","Silver Euro 50000","Gold Euro 100000","Multi Trip","30 Days","45 Days","60 Days","90 Days"],"required":true,"pdf_field":""},{"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, Illness/Injury, Treatment, IO No, App No, Client Code, Receipt No, Payer ID, From Date, To Date","type":"table","label":"Details of Insured persons","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical and Plan Details","fields":[{"help":"Enter date first treated for illness","type":"date","label":"Date first treated","options":[],"required":null,"pdf_field":""},{"help":"Provide doctor/surgeon details","type":"text","label":"Name of attending Medical Practitioner/ Surgeon with Address and Contact no.","options":[],"required":null,"pdf_field":""},{"help":"Specify plan option if individual","type":"text","label":"Plan option required in case of individual","options":[],"required":null,"pdf_field":""},{"help":"Specify floater plan option","type":"text","label":"In case of floater (a single plan to be selected)","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill 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 Declaration","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?   Yes   No.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Family Doctor Details","fields":[{"help":"Enter family doctor's name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter family doctor's address and contact number","type":"text","label":"Address & Contact No.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others"],"required":null,"pdf_field":""},{"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 for payment instrument","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 date of payment instrument","type":"date","label":"Instrument Date","options":[],"required":null,"pdf_field":""},{"help":"Enter transaction ID for online payment","type":"text","label":"Transaction ID (for online payments)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name of payment instrument","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account holder name for claim/refund","type":"text","label":"Bank Details (required for direct payment of claims/refunds): Name of the account holder","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name for claim/refund","type":"text","label":"Name of the bank","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account no.","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"Bank IFSC code","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code","type":"text","label":"MICR","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Savings","Current","Others"],"required":null,"pdf_field":""},{"help":"Specify if account type is Others","type":"text","label":"Others (please specify)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Document Delivery Preference","fields":[{"help":"Select if you want a physical policy document copy","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":"Declarations and Consent","fields":[{"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":"Declaration By Authorized Representative Or Person With Disability","fields":[{"help":"Proposer signature","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter authorized representative's name","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":"Authorized representative signature","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":true,"pdf_field":""},{"help":"Date of signature","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 signature","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 witness signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Intermediary Declaration","fields":[{"help":"Enter intermediary name","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"Enter intermediary code","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"Enter sales manager name","type":"text","label":"Sales Manager Name","options":[],"required":null,"pdf_field":""},{"help":"Enter sales manager code","type":"text","label":"Sales Manager Code","options":[],"required":null,"pdf_field":""},{"help":"Enter agent name","type":"text","label":"Intermediary / Agent Name","options":[],"required":null,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Intermediary / Agent signature","options":[],"required":null,"pdf_field":""},{"help":"Enter date and place","type":"text","label":"Date and Place","options":[],"required":null,"pdf_field":""},{"help":"Enter witness name","type":"text","label":"Witness Name","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Witness Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary/agent"}],"deadlines":[],"applies_to":"Schengen travel insurance proposals for individual or family floater plans, single or multi-trip options","attachments":["Request for authorisation form to receive Claim / Refund Payments directly into bank account (NEFT)"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge and is authorized to propose for others insured.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health after submission but before risk 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; false information may void policy and forfeit premium.","The proposer consents to receive service-related information electronically and understands data storage and usage policies.","The proposer declares premium is paid from legal sources and consents to document verification; insurer may reject proposal if not compliant.","The proposer confirms their status (HNI, NRI, Politically Exposed Person, etc.) as applicable.","The proposer agrees information will be processed as per insurer's privacy policy.","If ABHA number is shared, proposer consents to use of medical records for claims and insurance services.","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.","Optional consent to allow use of personal information for quality and data analysis by third-party vendors."],"dropped_labels":2},"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/2773-travel-suraksha-schengen-travel-proposal-form"}