{"id":2811,"title":"PUBLIC LIABILITY ACT 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/public-liability-act-insurance/proposal-forms/public-liability-act-insurance-retail-proposal-form.pdf","sha256":"58da5f9a73e22c0d6f462174a3b04c376565a1c878debf52ab6c3eed30c61db4","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (policyholder) to apply for Public Liability Act Insurance coverage under the Public Liability Insurance Act 1991.","notes":["Read prospectus/key features/policy wordings before completing the form.","Disclose all material facts fully and do not suppress any material facts.","Attach separate signed and dated sheet if space is insufficient for answers.","Cover commences only after acceptance and receipt of premium.","Use original documents where required.","If nominee permanent address is left blank, it will be considered same as present address.","There is a separate policy covering legal liability other than the Act Liability.","The form includes a prohibition of rebates under Section 41 of Insurance Act, 1938.","The insurer reserves the right to reject proposal or terminate contract and/or freeze funds if customer or associated persons are named in any recognized blacklist or sanctions list."],"title":"PUBLIC LIABILITY ACT INSURANCE PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name of the Proposer owner in full (see note)","options":[],"required":null,"pdf_field":""},{"help":"Include full address and PIN code","type":"text","label":"Present Address of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Include full address and PIN code","type":"text","label":"Permanent Address of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Business","options":[],"required":null,"pdf_field":""},{"help":"Central KYC Registry number if available","type":"text","label":"CKYC Number (if available)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Status and Details","fields":[{"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":null,"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":"yes-no","label":"If you are Differently Abled, please tick on the checkbox to provide confirmation.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If differently abled, specify type","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"If differently abled, specify percentage","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"If differently abled, provide UDID number","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Business and Risk Details","fields":[{"help":"Provide paid up capital as per note","type":"amount","label":"Paid up capital (See Note)","options":[],"required":null,"pdf_field":""},{"help":"List all hazardous substances handled","type":"text","label":"List of hazardous substances handled and Group/Owner (See Note)","options":[],"required":null,"pdf_field":""},{"help":"Provide details of accidents and compensation","type":"text","label":"Details of all accidents during past 3 years and compensation paid/claimed but not yet paid","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated turnover","type":"amount","label":"Estimated annual turnover (See note)","options":[],"required":null,"pdf_field":""},{"help":"Year for proposed insurance","type":"number","label":"(a) Proposed Insurance Year","options":[],"required":null,"pdf_field":""},{"help":"Previous year turnover","type":"number","label":"(b) Previous Year","options":[],"required":null,"pdf_field":""},{"help":"Number of workmen employees as per Workmen’s Compensation Act","type":"number","label":"Number of (a) Workmen Employees","options":[],"required":null,"pdf_field":""},{"help":"Number of other employees","type":"number","label":"(a) Other employees (See note)","options":[],"required":null,"pdf_field":""},{"help":"Specify indemnity limit","type":"amount","label":"Limit of Indemnity required in respect of Any one accident (AOA: AOY)","options":[],"required":null,"pdf_field":""},{"help":"Start date and time (AM/PM)","type":"date","label":"Policy period required: From","options":[],"required":null,"pdf_field":""},{"help":"End date","type":"date","label":"To midnight of","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Specify mode of payment","type":"choice","label":"Mode of Payment","options":[],"required":null,"pdf_field":""},{"help":"Provide payment details","type":"text","label":"Payment Details","options":[],"required":null,"pdf_field":""},{"help":"Premium amount paid","type":"amount","label":"Amount in (₹)","options":[],"required":null,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date of Payment (DD/MM/YY)","options":[],"required":null,"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":""},{"help":"Provide GSTIN or attach annexure if multiple","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","fields":[{"help":"Name on bank account for refund or claim","type":"text","label":"Name of bank account holder (mention specifically, if different from name of policyholder)","options":[],"required":null,"pdf_field":""},{"help":"Bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Bank Account Number","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"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 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","type":"text","label":"Permanent address: (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details of Nominee","fields":[{"help":"Nominee bank account holder name","type":"text","label":"Name of Account holder","options":[],"required":null,"pdf_field":""},{"help":"Nominee bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":null,"pdf_field":""},{"help":"Nominee bank account number","type":"text","label":"Bank Account Number","options":[],"required":null,"pdf_field":""},{"help":"Nominee bank IFSC code","type":"text","label":"IFS Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Authorized Person Details (if nominee is minor)","fields":[{"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 and Consent","fields":[{"help":"Sign the form; stamp if juridical person","type":"signature","label":"Signature of the Proposer(s) (Affix stamp, where proposer is a juridical person)","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","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"},{"title":"Intermediary Use Only","fields":[{"help":"Name of intermediary","type":"text","label":"Name of Insurance Agent/POSP/Specified Person of the Corporate Agent/Authorized Person of the Broker/IMF","options":[],"required":null,"pdf_field":""},{"help":"Code of intermediary","type":"text","label":"Intermediary’s Code","options":[],"required":null,"pdf_field":""},{"help":"Signature of intermediary","type":"signature","label":"Intermediary’s Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary"}],"deadlines":[],"applies_to":"Insurance under Public Liability Insurance Act 1991","attachments":["Separate signed and dated sheet if insufficient space to answer any question","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 statutory provisions relating to the business proposed for insurance are complied with.","All statements and particulars are true and no material fact is omitted, suppressed, misrepresented or misstated.","This declaration forms the basis of the contract between proposer and the Company.","If misrepresentation or suppression of material facts is found, the policy may be void and premium forfeited.","The policyholder will assist the insurer with records and information to address anti-financial crime practices.","Premium is paid from legitimate sources and insurer can verify source of funds and reject or terminate policy if otherwise.","Consent to receive policy and service communications electronically and for processing of personal data.","Consent to insurer accessing CKYC records for verification and receiving information via SMS/email.","Agreement to abide by insurer's Privacy Policy.","Insurer reserves right to reject proposal or terminate contract if proposer or associated persons are named in sanctions list.","KYC records are current and valid and proposer will inform insurer of any changes."],"dropped_labels":1},"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/2811-public-liability-act-insurance-proposal-form"}