{"id":2788,"title":"EMPLOYEE COMPENSATION INSURANCE POLICY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/other-insurance/employee-compensation-insurance-policy/proposal-forms/employee-compensation-insurance-proposal-form.pdf","sha256":"b6648402c50bfe24eb460394cd6eaeafc1598d225600c25549de608a7b6babca","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (employer or business) to apply for an Employee Compensation Insurance Policy covering liability towards employees and contractors. The proposer fills it.","notes":["Read prospectus/key features/policy wordings before completing the form.","Answer all questions; use additional signed sheets if needed.","Cover starts only after acceptance and premium receipt.","All persons employed must be included in the schedule.","Wages definition includes remuneration and certain benefits but excludes travel allowances and pension contributions.","Attach request for authorization form to receive claim/refund payments via NEFT if premium paid is more than Rs 10,000.","Physical copy of policy available on request; otherwise digital copy link will be sent.","Form includes sections for intermediary use only which are not to be filled by proposer."],"title":"EMPLOYEE COMPENSATION INSURANCE POLICY PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer and Insurance Period Details","fields":[{"help":"Full legal name of the proposer","type":"text","label":"2. Name of the Proposer (in full)","options":[],"required":null,"pdf_field":""},{"help":"Full present address including state and pin code","type":"text","label":"A. Present Address of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Permanent address if different from present address","type":"text","label":"B. Permanent address of the proposer (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Occupation and Risk Details","fields":[{"help":"Describe the occupation or profession of the proposer","type":"text","label":"3. Occupation / Profession","options":[],"required":null,"pdf_field":""},{"help":"Address(es) where the insured risk is located","type":"text","label":"4. Risk Location address","options":[],"required":null,"pdf_field":""},{"help":"Detailed description of the work activities to be insured","type":"text","label":"5. Particulars of work to be covered in Detail","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Identification and Status","fields":[{"help":"Central KYC Registry number if available","type":"text","label":"6. CKYC Number (if available)","options":[],"required":false,"pdf_field":""},{"help":"Select all applicable categories","type":"checkbox","label":"7. 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":null,"pdf_field":""},{"help":"Registration number for NGO/NPO if applicable","type":"text","label":"If you are an NGO/NPO, please provide Niti Ayog – Darpan Portal Registration Number","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"8. If you are Differently Abled, please tick on the checkbox to provide confirmation. Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify type of impairment if applicable","type":"text","label":"i. Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage of impairment if applicable","type":"number","label":"ii. Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Unique Disability ID number if applicable","type":"text","label":"iii. UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"Specify coverage details including state, pin code, telephone and mobile numbers","type":"text","label":"9. COVERAGE’S REQUIRED","options":[],"required":null,"pdf_field":""},{"help":"Fill limits and options for Employees Compensation, Common Law, Medical Expenses, Occupational Diseases, Contractors Employees as per policy terms","type":"table","label":"Coverage Scope of coverage Aggregate Limit of Indemnity Coverage Options [Yes/No]","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Employee and Contractor Details","fields":[{"help":"List contractor employees if coverage opted","type":"table","label":"CONTRACTORS EMPLOYEE DETAILS [if the coverage has been opted for] - Contractors Name, Registered Address, Declared Number of Employees, Total Declared wages during the period of insurance, Place/Places of Employment","options":[],"required":false,"pdf_field":""},{"help":"Confirm inclusion of all persons and contractors","type":"yes-no","label":"Does the above, schedule include- (a) All persons in your service? (b) All your contractors/subcontractors?","options":[],"required":null,"pdf_field":""},{"help":"Confirm compliance with statutory and safety regulations","type":"yes-no","label":"Do you comply with all statutory obligations, manufacturer's recommendations and other safety regulations in conduct of the Business.","options":[],"required":null,"pdf_field":""},{"help":"Confirm maintenance of accurate employee and wage records","type":"yes-no","label":"Do you maintain an accurate record of the Employees and Wages in respect of the Business in compliance with all statutory requirements.","options":[],"required":null,"pdf_field":""},{"help":"Provide insurer names if previously insured or proposed","type":"text","label":"Are you at present insured or have your ever proposed for an insurance in respect of your liability to your employees? If so, please give the name of the Company or Companies.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any proposal was declined or withdrawn","type":"yes-no","label":"Has any proposal for an insurance in respect of your liability to your employees or renewal thereof ever been declined or withdrawn? (a) Declined (b) Withdrawn","options":[],"required":null,"pdf_field":""},{"help":"Provide wages and loss details for past 3 years","type":"table","label":"State the total Wages paid and particulars of accidents to your employees during the past three years. Year [Past 3 years from this date], Wages Paid, Amount of Loss","options":[],"required":false,"pdf_field":""},{"help":"Provide wages and loss details for contractors for past 3 years","type":"table","label":"State the total wages paid and particulars of accidents to your contractors employees during the past three years. Year [Past 3 years from this date], Wages Paid, Amount of Loss","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Specify mode of payment","type":"text","label":"Mode of Payment","options":[],"required":null,"pdf_field":""},{"help":"Provide payment details","type":"text","label":"Payment Details","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Amount in (₹)","options":[],"required":null,"pdf_field":""},{"help":"Date when payment was made","type":"date","label":"Date of Payment (DD/MM/YY)","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN if premium is 100,000 INR or more","type":"text","label":"PAN (If premium is 1 Lac and Above.)","options":[],"required":false,"pdf_field":""},{"help":"Provide GSTIN(s) or attach annexure","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 refunds or claims","type":"text","label":"Bank details of proposer for refund or claim purpose: Name of bank account holder (mention specifically, if different from name of policyholder), Bank Name & Branch, Bank Account Number, IFS Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Nominee full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Nominee date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with the proposer","options":[],"required":null,"pdf_field":""},{"help":"Nominee mobile phone number","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Nominee email address","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Nominee present address","type":"text","label":"Address of Nominee: Present address","options":[],"required":null,"pdf_field":""},{"help":"Nominee permanent address if different","type":"text","label":"Permanent address (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"Provide authorized person details 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":"Declaration and Signature","fields":[{"help":"Sign the form","type":"signature","label":"Proposer’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Employee Compensation Insurance Policy","attachments":["Separate signed and dated sheet if additional space is needed for answers","Additional sheets for employee and contractor details if required","Annexure with GSTIN details if more than one GSTIN"],"declarations":["All statements and information provided are complete and accurate with no material facts withheld.","Misrepresentation or suppression of facts may render the policy void and premium forfeited.","Policyholder and related persons will assist insurer with anti-financial crime compliance.","Premium is paid from legitimate sources and insurer may verify source of funds.","Consent to receive communications electronically and for insurer to process personal data as per privacy policy.","Consent for insurer to access CKYC records for verification.","Insurer may reject or terminate policy if proposer or related persons are named on sanctions lists.","KYC records are current and proposer will inform insurer of any changes."],"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/2788-employee-compensation-insurance-policy-proposal-form"}