{"id":407,"title":"Mashak (Mosquito) Rakshak - Proposal Form","purpose":"proposal","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/icici-lombard-mashak-(mosquito)-rakshak8c0007ff45fd68ff8a0df0055f5f6899.pdf","sha256":"a070b3a5b7bbd16ce64436557c546de383ac85badce95562a69751f7299604a2","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is a proposal for the Mashak (Mosquito) Rakshak insurance policy by ICICI Lombard, to be filled by the proposer (customer) applying for the insurance.","notes":["Fill the proposal form in CAPITAL LETTERS","Answer all questions fully and correctly; mention 'not applicable' if a question does not apply","Insurance is a contract of utmost good faith; disclose all material facts until policy expiry","Policy liability starts only after premium receipt and proposal acceptance","Only last 4 digits to be entered where specified","Use original bills and documents for claims","For ABHA number generation visit ndhm.gov.in","Statutory warning on prohibition of rebates under Section 41 of Insurance Act, 1938"],"title":"Mashak (Mosquito) Rakshak - Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Part A: Customer / Proposer Information","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender   Male  Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth* D   D  / M  M  /  Y   Y   Y   Y","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age (Years)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Mailing Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Occupational details:","options":["Salaried","Self-employed / Business","Others"],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Fax Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Aadhar Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Are you an existing customer of ICICI Lombard Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, then kindly provide the policy number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"GSTIN Number (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Are you an ICICI group employee?   Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"PEP means Politically Exposed Person","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or a close relative of a PEP*? Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please give details:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part B: Insured Details","fields":[{"help":"For generating ABHA no. please visit ABHA number (ndhm.gov.in)","type":"choice","label":"I agree to share my medical records with ICICI Lombard / TPA through ABHA: Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured 4 Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part D: Risk Details","fields":[{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Policy Start Date D   D   / M M / Y   Y   Y   Y","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Tenure","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part E: Premium Details","fields":[{"help":"","type":"amount","label":"Net Premium (in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Applicable Taxes (in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Total Premium (in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Mode of Premium Payment Cheque  NEFT  RTGS  UPI","options":["Cheque","NEFT","RTGS","UPI"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is Policy on Auto-renewal Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Consent for ECS Yes  No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Name, Account No. & Account Type","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"MICR","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IFSC","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part F: Health Declaration","fields":[{"help":"","type":"yes-no","label":"I, hereby declare that none of the insured person listed in this form and intended to be covered under this policy suffer from any Vector Borne Disease.","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part G: General Declaration","fields":[{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date D  D   /  M  M   /  Y  Y  Y  Y","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Proposer's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Part H: Vernacular Declaration","fields":[{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date D   D    /   M M   /  Y   Y   Y   Y","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Proposer's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"person filling for proposer or proposer if signing in vernacular"},{"title":"Consent Letter","fields":[{"help":"","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"}],"deadlines":["Inform any changes in details immediately and not later than 30 days"],"applies_to":"Mashak (Mosquito) Rakshak insurance policy","attachments":["Self-attested copy of a valid government-issued identity proof of the Claimant/Insured (for claim processing)","Original hospitalization or day-care treatment-related documents (if collected at discharge but not submitted earlier)"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge","The policy comes into force only after full receipt of premium","Notify in writing any change in occupation or health after proposal submission and before risk acceptance or during policy period","Consent to company seeking medical information from doctors, hospitals, employers, and other insurers for underwriting and claims","Consent to share proposal and medical records with government and regulatory authorities","Consent to verify identity/address proof through Central KYC Registry or other modes","Premiums paid are from legally acquired sources of income","Details furnished are true and correct and changes will be informed within 30 days","False or misleading information may lead to liability and cancellation of insurance contract","Agent confirms having explained the proposal form contents and implications to the proposer","Consent letter authorizes ICICI Lombard to collect medical records for claim processing"],"dropped_labels":62},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/icici-lombard-general-insurance/407-mashak-mosquito-rakshak-proposal-form"}