{"id":4990,"title":"Super Surplus Insurance Policy - SHAI/PR0009","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Proposal_Form_Star_Specialized_Product_Proposal_Form_V_15_183a44b4c0.pdf","sha256":"8df90c591906a925626beadc7e84c5bd0c8332c7bd3a0476ad75c5db54b6105c","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is a proposal form for applying for the Super Surplus Insurance Policy and related special products. It is filled by the proposer who wishes to insure themselves and/or other persons.","notes":["Use detailed responses for health history questions; a dash is not sufficient.","Attach separate sheets if additional space is needed for medical conditions.","Cash payments are not eligible for 80D tax benefits.","Attach all relevant medical documents and reports as specified.","Provide accurate bank details and attach a cancelled cheque copy.","Multiple policies exceeding maximum sum insured may be cancelled ab-initio.","The form includes multiple product options; check brochure for available sum insured options."],"title":"Super Surplus Insurance Policy - SHAI/PR0009","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Declaration","fields":[{"help":"Read and agree to the declaration statements regarding accuracy of information, consent for KYC verification, medical information sharing, premium payment authorization, and conduct.","type":"text","label":"Declaration","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the person proposed for insurance","fields":[{"help":"Full name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender for each insured person","type":"choice","label":"Gender","options":["M","F","Transgender"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format for each insured person","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Height in centimeters for each insured person","type":"number","label":"Height (cms)","options":[],"required":false,"pdf_field":""},{"help":"Weight in kilograms for each insured person","type":"number","label":"Weight (kgs)","options":[],"required":false,"pdf_field":""},{"help":"Relationship of each insured person to the proposer","type":"text","label":"Relationship with proposer","options":[],"required":false,"pdf_field":""},{"help":"Occupation of each insured person","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"Annual income in rupees for each insured person","type":"amount","label":"Annual Income (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number if available for each insured person","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Insurance Coverage Details","fields":[{"help":"Provide details of existing insurance policies including company name, insurance period, sum insured, and policy number","type":"table","label":"1. Name of the Insurance Company and 2. Period of Insurance 3. Sum Insured (Rs) Policy No.","options":[],"required":false,"pdf_field":""},{"help":"List claims made under existing policies with ailment, year, and claim amount paid or rejected","type":"table","label":"Details of Claims: 1. Ailment for which Claim was made Year 2. Claim Amount Paid / Rejected","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health History","fields":[{"help":"Name of family physician","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""},{"help":"Phone number of family physician","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Registration number of family physician","type":"text","label":"Regn No","options":[],"required":false,"pdf_field":""},{"help":"Provide details if not in good health","type":"text","label":"1. Is the person proposed for insurance in good health free from physical and mental disease or infirmity. If not give details","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any illness or injury treatment","type":"text","label":"2. Has the person proposed for insurance consulted / diagnosed / taken treatment / been admitted for any illness / injury. If yes, give details","options":[],"required":true,"pdf_field":""},{"help":"Provide details and attach documents if yes","type":"text","label":"3. Does the person proposed for insurance have any complications during / following birth. If yes, please submit all necessary documents.","options":[],"required":true,"pdf_field":""},{"help":"Provide pregnancy duration and attach scan reports if applicable","type":"text","label":"4. Whether the insured person is pregnant if yes, kindly provide duration of pregnancy and scan reports","options":[],"required":true,"pdf_field":""},{"help":"Answer each sub-question with details including diagnosis date, duration, medication, and attach documents if needed","type":"text","label":"5. Has the person proposed for insurance ever suffered or suffering from any of the following (a to q)","options":[],"required":true,"pdf_field":""},{"help":"Provide details for each sub-question","type":"text","label":"6. Has the person proposed for insurance (a) Undergone any medical test? (b) Prescribed any medicines? If yes, provide illness, medicines, and period taken (c) Been advised for any surgery/treatment? (d) Received/receiving any payment for disability/injury/illness","options":[],"required":true,"pdf_field":""},{"help":"Provide habit details and related health issues","type":"text","label":"7. Does the person proposed for insurance has any of the mentioned habits (a) Chew Tobacco (b) Smoke (c) Consume Alcohol. If yes, since when and details of any related disease/complications","options":[],"required":true,"pdf_field":""},{"help":"Provide details and attach proof if positive","type":"text","label":"8. Is the person proposed for insurance positive for HIV, Hepatitis B/C. If yes, mention duration/date of diagnosis, medication details, CD4 count and Viral load (attach proof)","options":[],"required":true,"pdf_field":""},{"help":"List types and count of medical documents attached","type":"text","label":"9. Type and the total number of medical documents provided","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Options and Sum Insured Details","fields":[{"help":"Tick Silver or Gold plan for each insured person","type":"checkbox","label":"10. Applicable for Super Surplus Insurance Policy: Plan Option (Please Tick)","options":["Silver","Gold"],"required":false,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Tick Silver or Gold plan","type":"checkbox","label":"11. Applicable for Star Super Surplus (Floater) Insurance Policy: Plan Option (Please Tick)","options":["Silver","Gold"],"required":false,"pdf_field":""},{"help":"Select sum insured for Silver Plan","type":"choice","label":"Sum Insured Offered for Silver Plan (Rs.)","options":["10,00,000/-"],"required":false,"pdf_field":""},{"help":"Select deductible for Silver Plan","type":"choice","label":"Deductible for Silver Plan (Rs.)","options":["3,00,000/-","5,00,000/-"],"required":false,"pdf_field":""},{"help":"Select sum insured for Gold Plan","type":"choice","label":"Sum Insured for Gold Plan (Rs.)","options":["5,00,000/-","10,00,000/-","15,00,000/-","20,00,000/-","25,00,000/-","50,00,000/-","75,00,000/-","1,00,00,000/-"],"required":false,"pdf_field":""},{"help":"Select deductible for Gold Plan","type":"choice","label":"Deductible for Gold Plan (Rs.)","options":["3,00,000/-","5,00,000/-","10,00,000/-","15,00,000/-","20,00,000/-","25,00,000/-"],"required":false,"pdf_field":""},{"help":"Tick Plan A or Plan B","type":"checkbox","label":"12. Applicable for Diabetes Safe Insurance Policy: Plan Type (Please Tick)","options":["Plan - A","Plan - B"],"required":false,"pdf_field":""},{"help":"Tick Individual or Floater","type":"checkbox","label":"Policy Type (Please Tick)","options":["Individual","Floater"],"required":false,"pdf_field":""},{"help":"Tick sum insured for Floater","type":"checkbox","label":"Sum Insured Opted for Floater in Rs. (Please Tick)","options":["3,00,000","4,00,000","5,00,000","10,00,000"],"required":false,"pdf_field":""},{"help":"Enter sum insured for each insured person individually","type":"text","label":"Sum Insured Opted for Individual in Rs","options":[],"required":false,"pdf_field":""},{"help":"Provide doctor name, duration, attach reports, and fill test results","type":"text","label":"Details of Diabetes Mellitus: (i) Name of the Doctor consulted (ii) Duration of Diabetes Mellitus (attach recent reports not older than 90 days) (iii) Results: Fasting Blood Sugar, Serum Creatinine, HbA1c","options":[],"required":false,"pdf_field":""},{"help":"Provide insulin usage details if applicable","type":"text","label":"Is the Person proposed for insurance on Insulin. If yes, since when","options":[],"required":false,"pdf_field":""},{"help":"List diabetes medicines and duration","type":"text","label":"Mention medicines taken for Diabetes and since when","options":[],"required":false,"pdf_field":""},{"help":"Provide treatment details for listed conditions","type":"text","label":"Is the Person proposed for insurance taking / taken any treatment for (i) Any Heart Diseases (ii) Any problems relating to eyes (iii) Any problems relating to Kidneys (iv) Any non-healing wounded anywhere in the body (v) Any problems of the foot / hand","options":[],"required":false,"pdf_field":""},{"help":"Provide name of family member for personal accident insurance","type":"text","label":"Name of the family member chosen for Personal Accident Insurance under Section-4 (Applicable for Floater Policy Only)","options":[],"required":false,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Does the Insured's Occupation require to engage in manual labour?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify hazardous or adventurous activities if any","type":"text","label":"Does the Insured Person engage in or propose to engage in any activity or sport which is hazardous or adventurous in nature such as Racing, Mountaineering, Winter sport etc if so please specify","options":[],"required":false,"pdf_field":""},{"help":"Select sum insured offered","type":"choice","label":"13. Applicable for Star Special Care - (Details of the Insured Person): a) Sum Insured Offered (Rs.)","options":["3,00,000/-"],"required":false,"pdf_field":""},{"help":"Provide details of any such medical history","type":"text","label":"Has the person proposed for insurance consulted / taken treatment / been admitted for any illness/injury / disease / surgery / admitted in NICU at birth / admitted for recurrent fits etc. If Yes, give details","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"choice","label":"Are all the treatment details (as mentioned in no. 13(b) & 13(c) above) of the person proposed for insurance submitted","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer","fields":[{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Name of the Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Select account type or specify if others","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":true,"pdf_field":""},{"help":"Enter date of filling the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque copy","type":"attachment","label":"Please attach a photo copy of cancelled cheque leaf","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment (note: cash payments are not eligible for 80D tax benefits)","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","NEFT","ECS","Cash"],"required":true,"pdf_field":""},{"help":"Enter branch name for cheque/DD if applicable","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque or demand draft number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Super Surplus Insurance Policy and related special products including Star Super Surplus (Floater), Diabetes Safe, Star Special Care, and Star Cardiac Care Insurance Policies","attachments":["Photo copy of cancelled cheque leaf","Medical documents as applicable (e.g. scan reports, test reports, treatment records, autism assessment chart)","Birth discharge summary and prior treatment records for autism (if applicable)"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company is authorized to seek medical and insurance information for underwriting and claims.","The proposer consents to sharing information with government and regulatory authorities and service providers.","Concealment or misrepresentation will void the policy and claims.","The company reserves the right to not renew the policy in case of fraud or non-disclosure.","The proposer consents to premium deduction from the given bank account.","The proposer agrees to receive communications electronically and authorizes contact for service purposes.","The proposer agrees to professional conduct and acknowledges consequences of unprofessional behavior."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"044-69006900","label":"24 hours help-line","level":null,"hours":"24 hours","applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 425 2255","label":"Toll Free No.","level":null,"hours":"24 hours","applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be submitted while filing a reimbu","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"4th Floor, Balaji Complex, No.15, Whites Lane, Whites Road, Royapettah, Chennai-600014","label":"Grievance Redressal Officer postal address","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"tarhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, Balaji Complex, No.15, Whites Lane, Whites Road, Royapettah, Chennai-600014 lnsured person may also approach the grievance cell at any of the Company’s branches with the details of grievance. If","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@starhealth.in","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"e: In case of any grievance the Insured Person may contact the Company through\nWebsite | : www.starhealth.in\nE-mail | : gro@starhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, B","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"grievances@starhealth.in","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"rievance the Insured Person may contact the Company through\nWebsite | : www.starhealth.in\nE-mail | : gro@starhealth.in, grievances@starhealth.in\nPh. No. | : 044-69006900\nSenior Citizens may call at 044-69007500 Courier/Post : 4th Floor, Balaji Complex, No.15, Whit","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044-69006900","label":"Grievance Redressal Officer","level":1,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"xv) For assistance call 24 hours help-line 044-69006900 or Toll Free No. 1800 425 2255, Senior Citizens may call at 044-40020888 For the comprehensive list of documents to be","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"044-43664600","label":"Grievance Officer","level":2,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Prospectus_Super_Star_V_1_without_Premium_Chart_Single_Page_25b70db850.pdf","quote":"d with the redressal of grievance through one of the above methods, Insured Person may contact the grievance officer at 044-43664600.","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.starhealth.in/grievance-redressal","label":"Updated details of grievance officer","level":null,"hours":null,"applies_to":"all","source_url":"https://d28c6jni2fmamz.cloudfront.net/Policy_Star_Health_Assure_Insurance_Policy_V_9_c53663e68a.pdf","quote":"rson may contact the grievance officer at 044-43664600. For updated details of grievance officer, kindly refer the link https://www.starhealth.in/grievance-redressal If Insured Person is not satisfied with the redressal of grievance through above methods, the Insured Person may also a","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/star-health-and-allied-insurance/4990-super-surplus-insurance-policy-shai-pr0009"}