{"id":2828,"title":"Sukshma Hospi-Cash Group (Micro-Insurance Product) Proposal Form","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/commercial-insurance/sukshma-hospi-cash-group-micro-insurance-product/proposal-forms/sukshma-hospicash-group-proposal-form.pdf","sha256":"e2d5b77ac341c3dd92d6bfe4253fc40695150a296fb3396f2a370cb6d3310e92","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is for proposing group micro-insurance coverage under the Sukshma Hospi-Cash product. It is to be filled by the Group/Association/Institution/Corporate Body acting as the proposer.","notes":["Fields marked with * are mandatory.","Attach list of persons to be covered as per the attached format.","PAN is mandatory if premium exceeds Rs. One Lakh.","Request for authorization form must be filled to receive payments via NEFT if premium is more than Rs. 10,000.","Use the annexure for listing insured persons and nominees.","The form must be completed by the Group/Association/Institution/Corporate Body proposer.","The insurer will send digitally signed policy documents by default; tick if physical copy is desired.","The policy is subject to acceptance by the insurer and full premium payment.","The form includes declarations by proposer, intermediary, and authorized representatives if applicable.","The form includes a section for office use only which should not be filled by the proposer."],"title":"Sukshma Hospi-Cash Group (Micro-Insurance Product) Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Details of the Insured/Proposer","fields":[{"help":"Enter the full name of the proposer group or entity","type":"text","label":"Name of Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter the current address of the proposer","type":"text","label":"Present Address","options":[],"required":null,"pdf_field":""},{"help":"State of present address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal PIN code of present address","type":"number","label":"Pin","options":[],"required":null,"pdf_field":""},{"help":"Telephone number of proposer","type":"phone","label":"Telephone","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of proposer","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address of proposer","type":"email","label":"Email id*","options":[],"required":true,"pdf_field":""},{"help":"Tick if permanent address is same as present address","type":"checkbox","label":"Permanent Address (If same as above, please tick here) ☐","options":["same as present address"],"required":null,"pdf_field":""},{"help":"State of permanent address","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Postal PIN code of permanent address","type":"number","label":"Pin","options":[],"required":null,"pdf_field":""},{"help":"Telephone number at permanent address","type":"phone","label":"Telephone","options":[],"required":null,"pdf_field":""},{"help":"Mobile number at permanent address","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address at permanent address","type":"email","label":"Email id*","options":[],"required":true,"pdf_field":""},{"help":"Briefly describe the business or nature of the proposer","type":"text","label":"Description of the Proposer’s Business","options":[],"required":null,"pdf_field":""},{"help":"Describe how insured persons relate to the proposer","type":"text","label":"Relationship of the insured person(s) with the proposer","options":[],"required":null,"pdf_field":""},{"help":"Enter total number of persons to be insured initially; attach list as per format","type":"number","label":"Please mention the Total number of persons to be covered at the inception of policy :","options":[],"required":null,"pdf_field":""},{"help":"Enter WIN number if applicable","type":"text","label":"WIN NO","options":[],"required":null,"pdf_field":""},{"help":"Enter IO number if applicable","type":"text","label":"IO No","options":[],"required":null,"pdf_field":""},{"help":"Enter Application number if applicable","type":"text","label":"App No","options":[],"required":null,"pdf_field":""},{"help":"Enter client code if applicable","type":"text","label":"Client Code","options":[],"required":null,"pdf_field":""},{"help":"Enter receipt number if applicable","type":"text","label":"Receipt No","options":[],"required":null,"pdf_field":""},{"help":"Enter payer ID if applicable","type":"text","label":"Payer ID","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy and Coverage Details","fields":[{"help":"Enter start and end date of insurance coverage","type":"date","label":"Period of Insurance: From:  dd/mm/yyyy To dd/mm/yyyy","options":[],"required":null,"pdf_field":""},{"help":"Write the sum insured amount in words","type":"text","label":"Please mention the proposed Sum Insured at inception of policy. (in words)","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Please state whether all eligible members of the Group/ Association/ Institution/ Corporate Body are proposed for Insurance? ☐      Yes ☐      No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select the relationship type","type":"choice","label":"Relationship between Members/Beneficiaries and Group Manager : Employer–Employee☐ Non-Employer–Employee ☐","options":["Employer–Employee","Non-Employer–Employee"],"required":null,"pdf_field":""},{"help":"Describe relation of insured persons with proposer","type":"text","label":"Relation of the insured person(s) with the proposer","options":[],"required":null,"pdf_field":""},{"help":"Tick if you want a physical copy of the policy document","type":"choice","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, and 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":null,"pdf_field":""},{"help":"Provide PAN number if premium exceeds Rs. One Lakh","type":"text","label":"Whether PAN card is provided? if yes, please provide the PAN card no.","options":[],"required":null,"pdf_field":""},{"help":"Select the product option for number of days","type":"choice","label":"PRODUCT DETAILS Option:","options":["5 days","10 days","15 days","20 days","25 days"],"required":null,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy Type:","options":["Individual basis","Family Floater basis (Self, Spouse and maximum up to three dependent children up to 25 yrs)"],"required":null,"pdf_field":""},{"help":"Select daily cash amount in rupees","type":"choice","label":"Daily Cash Amount (Rs):","options":["100","200","300","400","500","600","700","800","900","1000"],"required":null,"pdf_field":""},{"help":"Select any optional covers required","type":"checkbox","label":"Optional Covers:","options":["Convalescence Benefit (can be offered for hospitalization of more than 10 days)","Pre-existing Disease Cover","Maternity Benefit Expense Cover with 9 months waiting period","Maternity Benefit Expense Cover without 9 months waiting period"],"required":null,"pdf_field":""},{"help":"Select deductible period","type":"choice","label":"Deductible opted:","options":["1 day","2 days","3 days"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter cheque number or NEFT reference","type":"text","label":"Premium paid by Cheque No/ NEFT","options":[],"required":null,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date: DD MM YYYY","options":[],"required":null,"pdf_field":""},{"help":"Name of bank from which payment was made","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Amount ((₹):","options":[],"required":null,"pdf_field":""},{"help":"Write premium amount in words","type":"text","label":"Amount (in words)","options":[],"required":null,"pdf_field":""},{"help":"Provide GSTIN(s) if applicable","type":"text","label":"GSTIN (If more than one GSTIN, kindly attach an annexure with details)","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN if premium is 1 lakh or more","type":"text","label":"PAN (if premium is 1 Lac and above.)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Date of signing declaration","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of proposer or group manager signing","type":"text","label":"Proposer’s/Group Manager Name","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature or thumb impression of proposer/group manager","type":"signature","label":"Proposer’s/Group Manager Signature/ Thumb Impression","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by Authorized Representative or Person with Disability","fields":[{"help":"Name of proposer authorizing representative","type":"text","label":"Name of Proposer","options":[],"required":null,"pdf_field":""},{"help":"Name of authorized representative","type":"text","label":"Name of Authorized Representative","options":[],"required":null,"pdf_field":""},{"help":"Relationship of authorized representative to proposer","type":"text","label":"Relationship with the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Address of authorized representative","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of authorized representative","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of the Authorized Representative","options":[],"required":null,"pdf_field":""},{"help":"Signature of proposer","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""},{"help":"Name of witness to authorization","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"authorized representative or proposer"},{"title":"Acknowledgement","fields":[{"help":"Application number assigned by insurer","type":"text","label":"Application No","options":[],"required":null,"pdf_field":""},{"help":"Date of acknowledgement","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of proposer acknowledged","type":"text","label":"Name of Proposer","options":[],"required":null,"pdf_field":""},{"help":"Amount received by cash/cheque","type":"amount","label":"Amount of Rs.","options":[],"required":null,"pdf_field":""},{"help":"Signature and seal of company official receiving application","type":"signature","label":"Signature of the receiver and official seal","options":[],"required":null,"pdf_field":""}],"filled_by":"insurance company"}],"deadlines":[],"applies_to":"Group micro-insurance policies under Sukshma Hospi-Cash product","attachments":["List of persons to be covered as per the format attached","Request for authorization form to receive claim/refund payments via NEFT","Annexure 1: List of Persons Proposed for Insurance"],"declarations":["The proposer declares all information given is true and complete and is authorized to propose for all persons insured.","The policy will come into force only after full payment of premium and acceptance by the company.","The proposer will notify any change in relationship between proposer and insured persons before risk acceptance.","The proposer consents to the company seeking medical and insurance information for underwriting and claims.","The company may share proposal information with government and regulatory authorities for underwriting and claims.","There is no undisclosed material information; if found untrue, policy is void and premium forfeited.","The proposer consents to receive service information electronically and understands no unsolicited messages will be sent.","Information provided will be stored and used for insurance and servicing purposes and the proposer consents to this.","Information will be processed as per the insurer's privacy policy.","If ABHA numbers are shared, proposer authorizes their use for accessing medical records for claims and servicing.","The proposer consents to CKYC record verification and receiving related communications."],"dropped_labels":7},"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/2828-sukshma-hospi-cash-group-micro-insurance-product-proposal-form"}