{"id":2850,"title":"Disability And HIV/AIDS Insurance Policy, Go Digit - Proposal Form (GODHLIP23185V012223)","purpose":"proposal","insurer":{"slug":"go-digit-general-insurance","name":"Go Digit General Insurance Limited"},"source_pdf":"https://www.godigit.com/content/dam/godigit/directportal/en/downloads/health/proposal-form-disability-and-hivaids-insurance-policy.pdf","sha256":"d7b6d1dce8d53b0699998fdf98478ff579c43bdb53ac94eb2bbb078d8db670ab","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for applying for Disability and HIV/AIDS Insurance Policy by Go Digit General Insurance Ltd. It is filled by the proposer who wishes to purchase the insurance.","notes":["Answer all questions correctly and completely.","Fields marked with * are mandatory.","Only Indian Nationals can be covered.","Only one policy can be purchased for this product across all insurers.","Coverage is effective only after proposal acceptance and premium payment realization.","Consent for receiving hard copy of policy and documents is requested; otherwise electronic delivery is provided.","For any doubts, contact agent/intermediary or call 1800 258 4242 or email hello@godigit.com.","Cheque for refund will be issued in the name of the proposer only.","If ECS is selected, submit standing instruction form available at branches.","Section 41 of Insurance Act 1938 prohibits rebating."],"title":"Disability And HIV/AIDS Insurance Policy, Go Digit - Proposal Form (GODHLIP23185V012223)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Contact Details","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Communication Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin-code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Select one and specify details if Other","type":"choice","label":"Profession","options":["Salaried","Self-Employed","Other"],"required":true,"pdf_field":""},{"help":"Describe your occupation and business nature","type":"text","label":"Occupation and Nature of Business/ Work","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number or Form 60/61","type":"text","label":"PAN No./ form 60/61","options":[],"required":false,"pdf_field":""},{"help":"12 digit Aadhaar number","type":"text","label":"AADHAAR No.","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Ayushman Bharat Health Account ID if available","type":"text","label":"ABHA ID (If Applicable)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Coverage Details","fields":[{"help":"","type":"choice","label":"Policy Type","options":["Individual Basis"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy period","options":["1 year"],"required":true,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance From DD/MM/YYYY to DD/MM/YYYY","options":[],"required":true,"pdf_field":""},{"help":"Select sum insured amount","type":"choice","label":"Sum Insured","options":["400000","500000"],"required":true,"pdf_field":""},{"help":"Select applicable coverage","type":"choice","label":"Coverage opted","options":["Pre-existing HIV/AIDS","Pre-existing Disability","Pre-existing HIV/AIDS and Disability"],"required":true,"pdf_field":""},{"help":"Select if waiver of co-payment is opted","type":"yes-no","label":"Waiver of Co-payment opted","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Person to be Insured","fields":[{"help":"Fill details for each person to be insured in the columns as labeled","type":"table","label":"Sr No, Name of the Insured, Nationality, Date of Birth, Age, Gender, Height, Weight, Occupation, ABHA ID, Marital Status, Relation with Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Details of Insured","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Do you suffer from HIV/AIDS?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach recent CD4 count certificate","type":"attachment","label":"If Yes, please enclose a recent certificate of your current CD4 count(within past 30 days)","options":[],"required":false,"pdf_field":""},{"help":"Enter current CD4 count value","type":"number","label":"Current CD 4 count","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has your CD4 Count gone below 500 in the past 4 years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of dates and frequency","type":"text","label":"If yes when and How many times","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you suffer from any other illness/ disease related to/ arising of/ associated to HIV/AIDS?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe other illness or disease","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you suffer from any disability as per the listed conditions mentioned below:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach disability certificate","type":"attachment","label":"If yes, please enclose Disability certificate mentioning percentage of disability wherever applicable","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you suffer from any pre-existing illness other than Disability or HIV AIDS mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide illness details and duration","type":"text","label":"If Yes, please specify details and the number of years you are suffering","options":[],"required":false,"pdf_field":""},{"help":"Describe other physical disabilities if any","type":"text","label":"Do you have any other physical disability arising out of any illness / disease condition?","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant medical information","type":"text","label":"Any other previous medical details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Insurance Details","fields":[{"help":"Enter previous policy or application number","type":"text","label":"Policy No./ Application No.","options":[],"required":false,"pdf_field":""},{"help":"Name of previous insurer","type":"text","label":"Insurer Name","options":[],"required":false,"pdf_field":""},{"help":"Enter insurance period","type":"text","label":"Period of Insurance (From - To)","options":[],"required":false,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Details of claims lodged","type":"text","label":"Claims lodged during the preceding years","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you have the same policy from any one or other insurer?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill details of other policies if applicable","type":"table","label":"If yes, Please share details below: Policy No./Application no., Insurer Name, Period of Insurance (From – To), Sum Insured, Claims lodged during the preceding years","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details","fields":[{"help":"Select if you want physical format","type":"yes-no","label":"I want related information in - Physical Format- Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you want electronic format","type":"yes-no","label":"e-Format (electronic) as & when applicable- Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select one insurance repository","type":"choice","label":"Choose your Insurance Repository (For those selecting e-Format)","options":["NSDL Data Management Ltd.","CDSL Insurance Repository Ltd","Karvy Insurance Repository Ltd.","CAMS Repository Services Ltd"],"required":false,"pdf_field":""},{"help":"Enter e Insurance Account number if available","type":"text","label":"I have e Insurance Account & the No. is","options":[],"required":false,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"My CKYC No. (Central Know Your Customer registry number) is (if available)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Customer Bank Account Details","fields":[{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Name of the bank","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of the insured person","type":"text","label":"Name of Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Name of nominee","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Nominee's mobile number","type":"phone","label":"Mobile number of Nominee","options":[],"required":false,"pdf_field":""},{"help":"Nominee's email address","type":"email","label":"E-mail Id of Nominee","options":[],"required":false,"pdf_field":""},{"help":"Nominee's current address","type":"text","label":"Present Address of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Nominee's permanent address if different","type":"text","label":"Permanent Address of Nominee (Not required, if same as present address)","options":[],"required":false,"pdf_field":""},{"help":"Relationship to insured person","type":"text","label":"Relationship of Nominee with Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Provide details if nominee is minor","type":"text","label":"Details of authorized person (If Nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim amount for nominee","type":"number","label":"Percentage of claim amount","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Details","fields":[{"help":"Name of person paying premium","type":"text","label":"Name of Premium payer","options":[],"required":true,"pdf_field":""},{"help":"Select payment frequency","type":"choice","label":"Premium Payment Frequency","options":["Monthly","Quarterly","Half Yearly"],"required":true,"pdf_field":""},{"help":"Enter premium amount in Indian Rupees","type":"amount","label":"Premium Amount (in INR)","options":[],"required":true,"pdf_field":""},{"help":"Select payment instrument type","type":"choice","label":"Instrument Type","options":["Cash","Cheque","Debit Card","Credit Card","Others"],"required":true,"pdf_field":""},{"help":"Specify if Others selected","type":"text","label":"Please Specify","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"Cheque number if applicable","type":"text","label":"Cheque no.","options":[],"required":false,"pdf_field":""},{"help":"Bank name for payment","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Bank account number for payment","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details and cancelled 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proceeds of crime.","The insurance company can cancel the contract if found guilty under Prevention of Money Laundering Act.","Agent declares having explained the proposal form contents and consequences of untrue statements or non-disclosure.","Proposer declares all statements are true and complete and is authorized to propose for all persons insured.","Policy comes into force only after full receipt of premium.","Proposer will notify any change in occupation or health after submission but before acceptance.","Proposer consents to company seeking medical and insurance information for underwriting and claims.","Proposer authorizes company to share proposal and medical records with government/regulatory authorities.","Proposer is aware of any premium loading for habits and diseases declared.","Proposer agrees to keep KYC records and provide beneficiary details as required."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"hello@godigit.com","label":"Customer Happiness Team Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"d App\n37K+ Reviews\nRated App\n7K+ Reviews\nDownload Digit App\nSelect Preferred Language\n×\nLogin\nDigit General\n70260 61234\nhello@godigit.com\naccount_circle\nMy Policy\nLogout\n70260 61234\nhello@godigit.com\nOur WhatsApp number cannot be used for calls. This is a c","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-258-5956","label":"Customer Support Phone","level":null,"hours":"24/7","applies_to":"all","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"ppiness team through any of the following options.\nEmail us at\nhello@godigit.com\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-258-4242","label":"Customer Support Phone","level":null,"hours":"24/7","applies_to":"all","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"ny of the following options.\nEmail us at\nhello@godigit.com\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit Protection of Policyh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"7026061234","label":"Chat with expert phone","level":null,"hours":"09 am to 10 pm","applies_to":"all","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"om\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit Protection of Policyholder Interest\r\n                      Policy –\nClick","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru 560095","label":"Grievance Redressal Officer Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":"y Policy\nCIN: L66010PN2016PLC167410, IRDAI Reg. No. 158.\nGo Digit General Insurance Limited | Corporate Office Address: Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru 560095 | Registered Office Address: 1 to 6 floors, Ananta One (AR One), Pride Hotel Lane, Narveer Tanaji Wadi, Shivaji Nagar,","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"grievance@godigit.com","label":"Grievance team email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"Team will review your complaint and provide you with a\r\n                        resolution within 14 days.\nEmail us at\ngrievance@godigit.com\nSubmit your Grievance\nClick Here\nEmail at\ncomplaints@irdai.gov.in\nRegister your complaint online at\nhttps://bimabharosa","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"adish.kanna@godigit.com","label":"Nodal Officer Andhra Pradesh, Telangana, Tamil Nadu & 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Singh\nhartej.singh@godigit.com\nRajasthan, Ma","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"hartej.singh@godigit.com","label":"Nodal Officer Punjab, Himachal Pradesh, Haryana (Except Gurgaon), Jammu & Kashmir","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":"ogesh R Yarde\nyogesh.yarde@godigit.com\nPunjab, Himachal Pradesh, Haryana (Except Gurgaon), Jammu & Kashmir\nHartej Singh\nhartej.singh@godigit.com\nRajasthan, Madhya Pradesh\nVipin Tyagi\nvipin.tyagi@godigit.com\nRest of Maharashtra (except Mumbai), Goa\nAshwin Deokar\nas","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"vipin.tyagi@godigit.com","label":"Nodal Officer Rajasthan, Madhya Pradesh","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":", Haryana (Except Gurgaon), Jammu & Kashmir\nHartej Singh\nhartej.singh@godigit.com\nRajasthan, Madhya Pradesh\nVipin Tyagi\nvipin.tyagi@godigit.com\nRest of Maharashtra (except Mumbai), Goa\nAshwin Deokar\nashwin.deokar@godigit.com\nUttar Pradesh and Uttarakhand\nRahul Tr","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"ashwin.deokar@godigit.com","label":"Nodal Officer Rest of Maharashtra (except Mumbai), Goa","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":"om\nRajasthan, Madhya Pradesh\nVipin Tyagi\nvipin.tyagi@godigit.com\nRest of Maharashtra (except Mumbai), Goa\nAshwin Deokar\nashwin.deokar@godigit.com\nUttar Pradesh and Uttarakhand\nRahul Tripathi\nrahul.tripathi@godigit.com\nWest Bengal, Jharkhand, Odisha and North East\nA","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"rahul.tripathi@godigit.com","label":"Nodal Officer Uttar Pradesh and Uttarakhand","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":"f Maharashtra (except Mumbai), Goa\nAshwin Deokar\nashwin.deokar@godigit.com\nUttar Pradesh and Uttarakhand\nRahul Tripathi\nrahul.tripathi@godigit.com\nWest Bengal, Jharkhand, Odisha and North East\nAshwani Kumar Chouhan\nashwani.chouhan@godigit.com\nNodal Officers Detail p","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"ashwani.chouhan@godigit.com","label":"Nodal Officer West Bengal, Jharkhand, Odisha and North East","level":null,"hours":null,"applies_to":"all","source_url":"https://www.godigit.com/claims","quote":"tarakhand\nRahul Tripathi\nrahul.tripathi@godigit.com\nWest Bengal, Jharkhand, Odisha and North East\nAshwani Kumar Chouhan\nashwani.chouhan@godigit.com\nNodal Officers Detail pertaining to Third Party Motor Accidents Claims\nState\nNodal Officer\nEmail ID\nGeneric Email Id\nHi","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-258-5956","label":"Motor helpline for complaints","level":null,"hours":"24/7","applies_to":"motor","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"ppiness team through any of the following options.\nEmail us at\nhello@godigit.com\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-258-4242","label":"Health helpline for complaints","level":null,"hours":"24/7","applies_to":"health","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"ny of the following options.\nEmail us at\nhello@godigit.com\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit Protection of Policyh","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/go-digit-general-insurance/2850-disability-and-hiv-aids-insurance-policy-go-digit-proposal-form-godhlip23185v012"}