{"id":2801,"title":"MACHINERY BREAKDOWN INSURANCE PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/other-insurance/machinery-breakdown-insurance/proposal-forms/machinery-breakdown-insurance-proposal-form-retail.pdf","sha256":"4a6d9c6481fd8d1e2fcfa051df2c1b388a43a2960620a629e73a99cbf3054b82","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for machinery breakdown insurance coverage from Generali Central Insurance Co. Ltd. The proposer fills it out to provide details about themselves, the machinery to be insured, and other relevant information.","notes":["Read the prospectus/key features document/policy wordings before completing the form.","Answer all questions fully; attach separate signed and dated sheets if needed.","Cover starts only after acceptance and receipt of premium.","If permanent address is left blank, it will be considered same as present address.","Use the Go Green initiative to receive policy documents electronically; tick box if physical copy is desired.","The form includes a section for intermediary use only, which is not to be filled by the proposer.","Anti-money laundering and anti-financial crime compliance is mandatory.","Section 41 of Insurance Act prohibits rebates as inducements for insurance."],"title":"MACHINERY BREAKDOWN INSURANCE PROPOSAL FORM","submit":{"to":"Generali Central Insurance Company Limited","how":"","address":"Registered Office: Unit No. 801 & 802, 8th Floor, Tower C, Embassy 247 Park, LBS Marg, Vikhroli (West), Mumbai – 400083\nEmail ID: gcicare@generalicentral.com\nToll-free Phone: 1800 220 233 / 1860 500 3333 / 022 6783 7800"},"purpose":"proposal","sections":[{"title":"Proposer Details and Insurance Period","fields":[{"help":"Enter start and end dates of the insurance coverage period","type":"date","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Enter full legal name of the proposer","type":"text","label":"Name of the Proposer (in full)","options":[],"required":null,"pdf_field":""},{"help":"Enter current residential or business address","type":"text","label":"A. Present Address of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"State of present address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of present address","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent address or leave blank if same as 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":""},{"help":"State of permanent address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Postal code of permanent address","type":"number","label":"Pin code","options":[],"required":false,"pdf_field":""},{"help":"Landline telephone number","type":"phone","label":"Telephone No","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Business and Location Details","fields":[{"help":"Describe the trade or business activity of the proposer","type":"text","label":"Proposer’s Trade or Business","options":[],"required":null,"pdf_field":""},{"help":"Enter the location address of the machinery to be insured","type":"text","label":"Address where plant to be insured is located","options":[],"required":null,"pdf_field":""},{"help":"State of plant location","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal code of plant location","type":"number","label":"Pin code","options":[],"required":null,"pdf_field":""},{"help":"Landline telephone number at plant location","type":"phone","label":"Telephone No","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number at plant location","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Central KYC Registry number if available","type":"text","label":"CKYC No. (if available)","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 applicable","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":"choice","label":"If you are Differently Abled, please tick on the checkbox to provide confirmation","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Describe impairment type if applicable","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage if applicable","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Unique Disability ID if applicable","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance and Machinery Condition Questions","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Do the items listed represent the whole of the plant? YES NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you at present insured? YES NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Name the insurer if currently insured","type":"text","label":"If YES, with whom?","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you aware of any defects/ damage existing in the machinery? YES NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Describe defects or damage if any","type":"text","label":"If YES, give details thereof","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Has your machinery sustained any damage from breakdown or other cause during last 3 years? YES NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide details of damage and repair costs","type":"text","label":"If YES, give details of damage(s) and repairing cost","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are regular periodical inspections of the machinery carried out? YES NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide name of inspector and inspection frequency","type":"text","label":"If YES, by whom and at what intervals?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Coverages on Payment of Additional Premium","fields":[{"help":"Enter amount or percentage or tick NO","type":"amount","label":"Escalation Amount/percentage: Rs. __________ OR _____________%","options":["NO"],"required":false,"pdf_field":""},{"help":"Enter amount or tick NO","type":"amount","label":"Express Freight (excluding Air Freight), Overtime and Holiday rates of Wages: Rs.","options":["NO"],"required":false,"pdf_field":""},{"help":"Enter amount or tick NO","type":"amount","label":"Air Freight: Rs.","options":["NO"],"required":false,"pdf_field":""},{"help":"Enter amount or tick NO","type":"amount","label":"Owners surrounding property: Rs.","options":["NO"],"required":false,"pdf_field":""},{"help":"Enter amounts for AOA and AOY or tick NO","type":"amount","label":"Third Party Liability: Rs. ___________ AOA Rs. _____________ AOY","options":[],"required":false,"pdf_field":""},{"help":"Enter amount or tick NO","type":"amount","label":"Additional Customs Duty: Rs.","options":["NO"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Specify payment mode","type":"text","label":"Mode of Payment","options":[],"required":null,"pdf_field":""},{"help":"Provide payment reference or details","type":"text","label":"Payment Details","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Amount in (₹)","options":[],"required":null,"pdf_field":""},{"help":"Enter date of payment","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":""}],"filled_by":"proposer"},{"title":"Bank Details of Proposer for Refund or Claim Purpose","fields":[{"help":"Enter bank account holder name","type":"text","label":"Name of bank account holder (mention specifically, if different from name of policyholder)","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter bank IFSC code","type":"text","label":"IFS Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with the proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's mobile number","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's email address","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's address","type":"text","label":"Address of Nominee","options":[],"required":null,"pdf_field":""},{"help":"Nominee's present address","type":"text","label":"Present address","options":[],"required":null,"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":"Provide nominee's bank account details","type":"text","label":"Bank Account Details of Nominee","options":[],"required":false,"pdf_field":""},{"help":"Bank account holder name for nominee","type":"text","label":"Name of Account holder","options":[],"required":false,"pdf_field":""},{"help":"Bank name and branch for nominee","type":"text","label":"Bank Name & Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank account number for nominee","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code for nominee","type":"text","label":"IFS Code","options":[],"required":false,"pdf_field":""},{"help":"Provide 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":"Declarations","fields":[{"help":"Sign the form","type":"signature","label":"Proposer’s Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Machinery Breakdown Insurance","attachments":["Separate signed and dated sheet if additional space is needed","Annexure with GSTIN details if more than one GSTIN","Request for authorization form to receive Claim/Refund payments through NEFT if premium paid is more than Rs 10,000/-"],"declarations":["All statements and information provided are complete and accurate and form the basis of the insurance contract.","Misrepresentation or suppression of material facts may render the policy void and premium forfeited.","The policyholder and related persons will assist the insurer with records and information to address anti-financial crime practices.","Premiums are paid from legitimate sources and the insurer may verify source of funds and reject or terminate policy if otherwise.","Consent is given to receive communications electronically and for processing of personal data as per privacy policy.","Consent is given for insurer to access CKYC records for verification and communication.","The insurer reserves the right to reject or terminate the contract if the proposer or associated persons are named in sanctions lists.","KYC records are current and proposer will inform insurer of any changes."],"dropped_labels":5},"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/2801-machinery-breakdown-insurance-proposal-form"}