{"id":2837,"title":"SAMPOORNA SURAKSHA- GRIHA (MICRO INSURANCE) PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/rural-insurance/sampoorna-suraksha-griha-micro-insurance/proposal-forms/sampoorna-suraksha-griha-micro-insurance-proposal-form.pdf","sha256":"e167f8b75f88e7fb077ada4ba180f111e832174d29751641d8b6159f8769df6d","pages":14,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or groups to apply for Sampoorna Suraksha-Griha micro insurance policy covering various sections like hospital cash, personal accident, building and contents, and others.","notes":["Read prospectus/key features/policy wordings before completing the form.","Answer all questions fully; attach separate signed sheet if needed.","Cover starts only after acceptance and premium receipt.","If nominee is minor, provide guardian name.","If parents are covered, child above 90 days can be covered.","Use replacement value for sum insured calculations.","Pump sets must have ISI mark to be covered.","Policyholder must fill request for authorization form for NEFT payments if premium > ₹10,000.","No rebates allowed as per Section 41 of Insurance Act, 1938."],"title":"SAMPOORNA SURAKSHA- GRIHA (MICRO INSURANCE) PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Product Details","fields":[{"help":"Select whether the proposal is for an individual or a group","type":"choice","label":"Type: Individual / Group","options":["Individual","Group"],"required":null,"pdf_field":""},{"help":"Tick all the insurance sections you want to opt for","type":"checkbox","label":"Sections opted","options":["Hospital Cash Plan A (`175/hospital cash benefit/ day)","Hospital Cash Plan B (`250/hospital cash benefit/ day)","Hospital Cash Plan C (`300/hospital cash benefit/ day)","Personal Accident","Building and Contents","Robbery and Burglary","Farm Produce","Agricultural Pump set","Cart Protection & Liability","Pedal Cycle"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proposer Details","fields":[{"help":"Enter full name with title","type":"text","label":"Name: Mr. / Ms.","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth or age","type":"date","label":"Date of Birth/ Age","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender: Male/ Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter full present address","type":"text","label":"Present Address of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter state of present address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin-code","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address or leave blank if same as present","type":"text","label":"Permanent address of the proposer (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code of permanent address","type":"number","label":"Pin-code","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Enter Central KYC number if available","type":"text","label":"CKYC Number (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":"Enter 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. Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If differently abled, specify type of impairment","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":""},{"help":"List all insured parties","type":"text","label":"Policy to be issued in favour of (list out all the parties who have insurable interest) including the financial institutions","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance desired: From (dd/mm/yyyy) to (dd/mm/yyyy)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Hospital Cash - Details of the Insured","fields":[{"help":"Enter name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender for each insured","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter date of birth or age for each insured","type":"date","label":"Date of Birth/ Age","options":[],"required":true,"pdf_field":""},{"help":"Enter marital status for each insured","type":"text","label":"Marital Status","options":[],"required":false,"pdf_field":""},{"help":"Enter occupation for each insured","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"Enter income for each insured","type":"amount","label":"Income","options":[],"required":false,"pdf_field":""},{"help":"Enter address for each insured","type":"text","label":"Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter pin code for each insured","type":"number","label":"Pin code*","options":[],"required":true,"pdf_field":""},{"help":"Enter residence telephone number","type":"phone","label":"Residence Telephone*","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E mail id","options":[],"required":false,"pdf_field":""},{"help":"Signature of each insured","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Personal Accident","fields":[{"help":"Enter name of insured persons","type":"text","label":"Named Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter age of insured persons","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to primary insured","type":"text","label":"Relationship with the insured","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee name","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Specify any existing disability","type":"text","label":"Existing disability, if any","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Fire and Building Contents","fields":[{"help":"Indicate if existing policy is in place","type":"yes-no","label":"Is there any policy in place for the same property? Yes/No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of existing policy","type":"text","label":"If Yes, please provide the details","options":[],"required":false,"pdf_field":""},{"help":"Enter full address and pin code","type":"text","label":"Location of Home Building - full postal address with Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Specify building type","type":"text","label":"Is it in a multi-storey building or is it a standalone house?","options":[],"required":true,"pdf_field":""},{"help":"Enter floor number if applicable","type":"number","label":"In case of multi-storey building, please provide the floor number of Your house","options":[],"required":false,"pdf_field":""},{"help":"Indicate if basement exists","type":"yes-no","label":"Is there a basement to Your house?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter sum insured for additional structures","type":"amount","label":"b. SI for additional structures (in ₹)","options":[],"required":false,"pdf_field":""},{"help":"Enter carpet area in square meters","type":"number","label":"Carpet area of structure of Home in square metres","options":[],"required":true,"pdf_field":""},{"help":"Enter cost rate per square meter","type":"amount","label":"Rate of Cost of Construction per square metre at the policy Commencement Date","options":[],"required":true,"pdf_field":""},{"help":"Select age category","type":"choice","label":"Age of Home Building (Less than 5 Years / 5-10 Years / 10-20 Years / Above 20 Years)","options":["Less than 5 Years","5-10 Years","10-20 Years","Above 20 Years"],"required":true,"pdf_field":""},{"help":"Enter sum insured for basement contents","type":"amount","label":"In case of Basement, If there are contents in it, please provide the Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Indicate if personal accident cover is required","type":"yes-no","label":"Do You require ‘Personal Accident Cover’ for Yourself and Your spouse? Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide spouse details if cover required","type":"text","label":"Name & age of Your spouse","options":[],"required":false,"pdf_field":""},{"help":"Provide your age if cover required","type":"number","label":"Your age","options":[],"required":false,"pdf_field":""},{"help":"Indicate if cover for valuable contents is required","type":"yes-no","label":"Do You require ‘Cover for Valuable Contents on Agreed Value Basis (under Home Contents cover)’: Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach list of valuable items and sum insured","type":"attachment","label":"If Yes, please attach list of items and Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Indicate if valuation certificate is attached","type":"yes-no","label":"Valuation certificate attached? (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Robbery and Burglary","fields":[{"help":"Describe contents insured","type":"text","label":"Contents of Farmhouse","options":[],"required":false,"pdf_field":""},{"help":"Deductible is 5% of Sum Insured subject to minimum ₹500 and maximum ₹10,000 per claim","type":"text","label":"Deductible","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Farm Produce","fields":[{"help":"List farm produce details and storage locations","type":"table","label":"Details of Farm Produce & Storage Location, Sub-limit of Sum Insured if any","options":[],"required":true,"pdf_field":""},{"help":"Deductible is 5% of Sum Insured per claim","type":"text","label":"Deductible","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agricultural Pumpset","fields":[{"help":"Indicate working condition","type":"yes-no","label":"Is the Pump Set in working condition? Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Deductible is 1% of Sum Insured or ₹100 whichever is less per claim","type":"text","label":"Deductible","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Cart Protection and Liability","fields":[{"help":"Limit not exceeding AOA- ₹10,000 / AOY- ₹25,000","type":"amount","label":"Third Party Liability Limit of Indemnity","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Pedal Cycle","fields":[{"help":"Enter total sum insured","type":"amount","label":"Total Sum Insured","options":[],"required":true,"pdf_field":""},{"help":"Limit not in excess of ₹5,000 AOA/AOY","type":"amount","label":"Third Party Liability Limit of Indemnity","options":[],"required":false,"pdf_field":""},{"help":"Deductible ₹100 per claim","type":"text","label":"Deductible","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Miscellaneous","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Over the preceding 5 year period, have you (or any person proposed to be insured) made any claim under any insurance policy in respect of any of the insurance covers now proposed?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Had any claim under any insurance policy declined or refused in whole or in part?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Had any insurance cancelled, or accepted on special terms or conditions or rates?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Any Other Information","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Specify payment mode","type":"text","label":"Mode of Payment","options":[],"required":true,"pdf_field":""},{"help":"Provide payment details","type":"text","label":"Payment Details","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Amount in (₹)","options":[],"required":true,"pdf_field":""},{"help":"Enter payment date","type":"date","label":"Date of Payment (DD/MM/YY)","options":[],"required":true,"pdf_field":""},{"help":"Provide PAN if applicable","type":"text","label":"PAN (If premium is 1 Lac and Above.)","options":[],"required":false,"pdf_field":""},{"help":"Provide GSTIN 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":true,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFS Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with the proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee mobile number","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee email","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee present address","type":"text","label":"Address of Nominee: Present address","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address or leave blank","type":"text","label":"Permanent address (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name","type":"text","label":"Bank Account Details of Nominee: Name of Account holder","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFS Code","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":"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"},{"title":"For Intermediary Use Only","fields":[{"help":"Enter intermediary name","type":"text","label":"Name of Insurance Agent/POSP/Specified Person of the Corporate Agent/Authorized Person of the Broker/IMF","options":[],"required":true,"pdf_field":""},{"help":"Enter intermediary code","type":"text","label":"Intermediary’s Code","options":[],"required":true,"pdf_field":""},{"help":"Intermediary to sign","type":"signature","label":"Intermediary’s Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"}],"deadlines":[],"applies_to":"Micro Insurance policies under Sampoorna Suraksha-Griha","attachments":["Separate signed and dated sheet if additional space is needed","List of items and Sum Insured for Valuable Contents if opted","Valuation certificate if required","Annexure with GSTIN details if more than one GSTIN"],"declarations":["All statements and information provided are complete and accurate with no relevant information withheld.","If misrepresentation or suppression of material facts is found, the policy may be void and premium forfeited.","Policyholder and related persons will assist the insurer with records and information to address anti-financial crime practices.","Premium is paid from legitimate sources and insurer may 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 as per privacy policy.","Consent for insurer to access CKYC records for verification and communication.","Obligation to keep CKYC records current and inform insurer of changes.","Insurer reserves right to reject proposal or terminate contract if persons are named in sanctions list."],"dropped_labels":19},"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/2837-sampoorna-suraksha-griha-micro-insurance-proposal-form"}