{"id":4991,"title":"Star Hospital Cash Insurance Policy - Proposal Form","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_Hospital_Cash_V_8_Web_160f4a21fd.pdf","sha256":"ebe7be8ccf45c0c731eff91fb5735c26bba2b772bc81618644f0503e3cc40064","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer to apply for the Star Hospital Cash Insurance Policy by providing personal, nominee, and policy details along with payment information.","notes":["Fill the form in block letters.","Use original documents for proofs.","Attach passport size photograph of proposer and stamp size photographs of insured persons.","Nomination form is mandatory and must be attached.","If proposer is illiterate or signs in a different language, the details must be explained and confirmed.","Beware of fraudulent calls or emails asking for personal or payment information.","Payment can be made annually, biennially, or triennially depending on policy term.","If PAN number is not available, submit Form 60.","Politically Exposed Persons (PEPs) must be disclosed.","The proposer should read and understand the product features before signing."],"title":"Star Hospital Cash Insurance Policy - Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Ref. No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Business Type","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you a ASHA worker","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you a MGNREGA worker","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Tick applicable category if Yes above","type":"choice","label":"If Yes (please tick)","options":["Unorganized Sector","Economically Vulnerable or Backward Classes","Other Categories of Persons","Informal Sector"],"required":null,"pdf_field":""},{"help":"Enter proposer’s first name","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"Enter middle name if any","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Enter proposer’s last name","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"Enter father or spouse name","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"Enter mother’s name","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / Thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Payment of Rs.","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque or DD number","type":"text","label":"by cash/vide cheque/DD no.","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque/DD date","type":"date","label":"dated","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name on which cheque/DD is drawn","type":"text","label":"drawn on","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you (Proposer) or any of the insured person is a PEP (Politically Exposed Person) or related to PEP","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Enter current address line 1","type":"text","label":"Current Address - Address line 1","options":[],"required":true,"pdf_field":""},{"help":"Enter city, town or village","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter country and postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address line 1","type":"text","label":"Permanent Address (should be same as address Proof) - Address line 1","options":[],"required":true,"pdf_field":""},{"help":"Enter city, town or village","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter country and postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter alternate mobile number if any","type":"phone","label":"Alternate Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Attach one valid ID and address proof","type":"choice","label":"Please attach any one proof in support of ID and Address","options":["Voter ID","Driving License","Aadhar Card","Passport","NREGA Job Card"],"required":true,"pdf_field":""},{"help":"Enter nominee’s full name","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship to nominee","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter appointee’s name if nominee is minor","type":"text","label":"Name of the Appointee (if nominee is a minor)","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you wish to receive the physical copy of the policy document","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter eIA number if available","type":"text","label":"If you already have an e-Insurance Account (eIA) number, please provide:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select policy term","type":"choice","label":"Please choose the Policy Term Opted","options":["1 yr","2 yrs","3 yrs"],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Select source of income","type":"choice","label":"Source of Income","options":["Salaried","Business"],"required":true,"pdf_field":""},{"help":"Provide IT returns for last 3 months if applicable","type":"text","label":"IT Returns 3mths","options":[],"required":false,"pdf_field":""},{"help":"Enter annual income in rupees","type":"amount","label":"Payslip Annual Income (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number or submit Form 60 if not available","type":"text","label":"PAN Number","options":[],"required":true,"pdf_field":""},{"help":"Enter GST number if applicable","type":"text","label":"GST Number","options":[],"required":false,"pdf_field":""},{"help":"Select residential status","type":"choice","label":"Residential Status","options":["Indian Resident","NRI","PIO","Foreign National"],"required":true,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"CKYC Number","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Specify any other proof submitted","type":"text","label":"Other Proof, please specify","options":[],"required":false,"pdf_field":""},{"help":"Specify proof of income documents submitted","type":"text","label":"Proof of Income to be submitted","options":[],"required":false,"pdf_field":""},{"help":"Specify other details if any","type":"text","label":"Others, please specify","options":[],"required":false,"pdf_field":""},{"help":"Enter proposer name as per KYC/ID proof","type":"text","label":"Proposer Name (same as KYC/ID proof)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nomination Details","fields":[{"help":"Enter nominee’s full name","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship to nominee","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter appointee’s name if nominee is minor","type":"text","label":"Name of the Appointee (if nominee is a minor)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Health Insurance Policies","fields":[{"help":"List all health insurance policies under which the lives proposed are covered","type":"table","label":"Name of the Insurance Company and Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature / Thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["Contact the office if policy is not received within 15 days from the date of payment of premium"],"applies_to":"Star Hospital Cash Insurance Policy","attachments":["Passport size photograph of the Proposer","Stamp size photograph of each Insured Person","Proof of ID and Address (one of Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card)","Copy of PAN card or Form 60","Annexure to Proposal Form (Nomination Form)"],"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 premium and acceptance by the insurer.","The proposer will notify any change in occupation or health before risk acceptance.","The insurer may seek medical and other information for underwriting and claim settlement.","The proposer consents to sharing of information with government and regulatory authorities and service providers.","Concealment or misrepresentation may lead to policy cancellation and claim repudiation.","The insurer reserves the right to not renew the policy in case of fraud or non-disclosure.","The proposer consents to electronic communication and premium deduction from bank account.","The proposer confirms the source of premium funds is legal and no third-party payments are allowed."],"dropped_labels":9},"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/4991-star-hospital-cash-insurance-policy-proposal-form"}