{"id":2774,"title":"Student Suraksha | Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/travel-insurance/future-student-suraksha/proposal-forms/student-suraksha-proposal-form.pdf.pdf","sha256":"d849d4ae137bed65a956164727c566a242223eb47d3a56af94b50b0d18b7c128","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Student Suraksha insurance policy for students studying overseas. The proposer fills the form with personal, health, course, and nominee details.","notes":["Information for fields marked with asterisk [*] is mandatory.","Proposer must be 18 years or older; for students below 18, parent/legal guardian must be proposer.","PAN is mandatory if premium exceeds Rs. 50,000 in cash or Rs. 1,00,000 in any mode.","Provide ABHA number for all insured persons or create one online.","Attach separate sheets if space is insufficient for health details.","Fill and attach authorization form for NEFT payments if premium is more than ₹10,000.","Policy document will be sent digitally; tick box if physical copy is desired.","Use block letters and provide accurate information to avoid rejection or cancellation.","The form includes declarations by intermediary and witness if proposer signs by thumb impression.","Section 41 of Insurance Act prohibits rebates; violation may lead to penalty."],"title":"Student Suraksha | Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of the Proposer","fields":[{"help":"Enter full name and select appropriate title; proposer must be 18 years or older or parent/legal guardian if student is below 18","type":"text","label":"Name of the Proposer (in full) *#  Mr.  Mrs.  Ms.","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address and Other Details: State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","options":[],"required":true,"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":"Present address state if different","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Present address PIN code if different","type":"number","label":"Pin code","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. 1,00,000 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 gender","type":"choice","label":"Gender*","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","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":""}],"filled_by":"proposer"},{"title":"Details of the Insured","fields":[{"help":"Enter full name and select title","type":"text","label":"Name of the Insured (in full)*  Mr.  Mrs.  Ms.","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal PIN code","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone no","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile no*","options":[],"required":true,"pdf_field":""},{"help":"Provide Ayushman Bharat Health Account number or create one at https://healthid.ndhm.gov.in/register","type":"text","label":"ABHA No^^","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email id","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","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":"Enter residential status","type":"text","label":"Residential Status","options":[],"required":false,"pdf_field":""},{"help":"Select visa type","type":"choice","label":"Visa Type*","options":["Immigrant","Resident","Student","Travel"],"required":true,"pdf_field":""},{"help":"Enter passport number","type":"text","label":"Passport Number","options":[],"required":false,"pdf_field":""},{"help":"Enter educational qualification","type":"text","label":"Educational Qualification","options":[],"required":false,"pdf_field":""},{"help":"Enter state of contact address in India","type":"text","label":"Contact address in India State","options":[],"required":false,"pdf_field":""},{"help":"Enter PIN code of contact address","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number of contact address","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number of contact address","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Course to be Undertaken Overseas","fields":[{"help":"Enter name of the course","type":"text","label":"Course to pursue*","options":[],"required":true,"pdf_field":""},{"help":"Enter country name","type":"text","label":"Country to be visited for further studies*","options":[],"required":true,"pdf_field":""},{"help":"Enter name of university or school","type":"text","label":"University / School Name","options":[],"required":false,"pdf_field":""},{"help":"Enter course fees amount","type":"amount","label":"Course fees","options":[],"required":false,"pdf_field":""},{"help":"Enter duration of the course","type":"text","label":"Course duration","options":[],"required":false,"pdf_field":""},{"help":"Enter university address state","type":"text","label":"University address State","options":[],"required":false,"pdf_field":""},{"help":"Enter university address PIN or ZIP code","type":"number","label":"Pin/ Zip","options":[],"required":false,"pdf_field":""},{"help":"Enter university address country","type":"text","label":"Country","options":[],"required":false,"pdf_field":""},{"help":"Enter university telephone number","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Enter university email address","type":"email","label":"E Mail","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Sponsor in India","fields":[{"help":"Enter sponsor's name and title","type":"text","label":"Name: Mr. / Ms","options":["Mr.","Ms."],"required":false,"pdf_field":""},{"help":"Enter relationship to insured","type":"text","label":"Relationship with the insured","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of birth","options":[],"required":false,"pdf_field":""},{"help":"Enter sponsor's address state","type":"text","label":"Address State","options":[],"required":false,"pdf_field":""},{"help":"Enter sponsor's PIN code","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Enter sponsor's telephone number","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Enter sponsor's mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter sponsor's email address","type":"email","label":"E Mail","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health","fields":[{"help":"Answer only if female insured","type":"yes-no","label":"Questions to be answered by Female Insureds (Strike off for all Male Insured): 1. Have you ever suffered /are you suffering from Gynecological problems?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Answer only if female insured","type":"text","label":"Are you Pregnant at present? (i) If yes, mention the duration in weeks (ii) Any complications, miscarriage, medical termination of pregnancy or Caesarian?","options":[],"required":null,"pdf_field":""},{"help":"Answer only if female insured; provide details if yes","type":"text","label":"Have you ever undergone any investigation or treatment or received medical advice or consulted a physician for: (i) Any disease or disorder of the Cervix, Uterus, Ovary (ies) or Vagina, abnormal bleeding, Cancer or abnormal growth? (ii) Any disease or disorder of the Breast(s) such as Breast Lump/cyst, Fibrocystic disease, Nipple changes or discharge, cancer or growth? (iii) Have you undergone any mammogram or Pap smear? (If yes, then kindly provide date and the test result)","options":[],"required":null,"pdf_field":""},{"help":"Attach separate sheets if space is insufficient","type":"table","label":"If answer to any of V. A to B. question is “Yes”, please provide the below mentioned details: Details of the Treating/ Family Doctor, Nature of ailment /Disease/Exact Diagnosis etc, First Date of Diagnosis, Details of current symptoms (onset, intensity and duration), List the current prescriptions or medicines taken for disorder, Is there any further consultation Planned","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Product Details","fields":[{"help":"Tick applicable coverage option","type":"checkbox","label":"Coverage ( Tick Mark whichever is applicable )","options":["Worldwide","Excluding USA & Canada","Asia- Pacific excluding Japan"],"required":true,"pdf_field":""},{"help":"Tick applicable plan","type":"checkbox","label":"Plan ( Tick Mark whichever is applicable )","options":["Basic USD-50,000","Standard USD- 50,000","Silver USD- 100,000","Silver USD- 150,000","Gold USD- 200,000","Gold USD- 250,000","Platinum USD- 500,000","USD- 25000"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill details for up to 4 appointees 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 (If same as above, please tick here) ☐, Relationship with Appointee, Specify the Percentage (%) of Claim amount payable to each nominee in the event of the policyholder’s death (total must not exceed 100%), Bank details of the Appointee: Account No., IFSC/MICR Code, Name of the Bank, Account Holder Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select payment method","type":"choice","label":"Payment Option","options":["Cheque","Demand Draft","Fund Transfer","Pay Order","Debit Card","Credit Card","Others (please specify)"],"required":true,"pdf_field":""},{"help":"Enter premium amount and amount in words","type":"amount","label":"Premium Amount : ₹________ Amount in Words:","options":[],"required":true,"pdf_field":""},{"help":"Enter account holder name for payment","type":"text","label":"Account Holder Name","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque/draft/instrument number","type":"text","label":"Instrument Number","options":[],"required":false,"pdf_field":""},{"help":"Enter instrument date","type":"date","label":"Instrument Date","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction ID for online payments","type":"text","label":"Transaction ID (for online payments)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Fill bank details for claim/refund payments; mandatory if premium > ₹10,000","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: ☐ Savings ☐ Current ☐ Others (please specify)","options":["Savings","Current","Others"],"required":false,"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":null,"pdf_field":""},{"help":"Attach signed authorization form for NEFT payments if premium > ₹10,000","type":"attachment","label":"Request for authorisation form attached with this Proposal Form to receive Claim / Refund Payments, if any, directly into your bank account through NEFT. It is necessary where the premium is more than ₹ 10,000/-.","options":[],"required":true,"pdf_field":""},{"help":"Tick if you want a physical copy of the policy document","type":"checkbox","label":"True to our Go Green initiative, we will send the digitally signed and authenticated policy document to your e-mail address, as you’ve mentioned In this proposal, you may download and save a copy of it. 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","fields":[{"help":"Enter proposer 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":""},{"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":"Enter relationship to proposer","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 signing","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 signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Student Suraksha insurance policy proposal","attachments":["Request for authorisation form to receive Claim / Refund Payments directly into bank account through NEFT (mandatory if premium > ₹10,000)"],"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 after proposal submission and before acceptance.","Consent to insurer seeking medical and other 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 as per privacy policy.","Premium paid is from legal sources; insurer may verify source and reject proposal if suspicious.","Proposer declares applicable categories such as HNI, NRI, Politically Exposed Person, etc.","Consent to share ABHA number for medical record verification and claims facilitation.","Consent to processing of data as per insurer's privacy policy.","Consent to insurer downloading CKYC record for KYC verification.","KYC records are current and valid and will be updated as needed.","Optional consent to use personal information for quality and data analysis by third parties."],"dropped_labels":3},"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/2774-student-suraksha-proposal-form"}