{"id":4992,"title":"Common Proposal Form 1","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Offline_Proposal_Form_138e10d5db.pdf","sha256":"ca3c33d9bdc5f52898743c69956864b4cc2329ae79a82bf2b87f9ffca0b06bf3","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals (proposers) to apply for health insurance policies offered by Star Health and Allied Insurance Company Limited. The proposer fills it to provide personal, health, and policy details for insurance coverage.","notes":["Fill the form in block letters","Attach original or valid proofs as specified","Patient Care add-on is only for insured persons above 60 years","Cash payments are not eligible for 80D tax benefits","Use the brochure for details on policy terms, instalment options, and sum insured options","Beware of fraudulent calls and do not share sensitive information like passwords or OTPs","Insurance is a contract of utmost good faith; disclose all relevant information honestly","Multiple policies exceeding maximum sum insured may be cancelled ab-initio","If proposer is illiterate or signs in a different language, details must be explained and signed by a witness"],"title":"Common Proposal Form 1","submit":{"to":"Star Health and Allied Insurance Company Limited","how":"","address":"Registered Office: No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034"},"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":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Select source of income and provide annual income in Rs.","type":"choice","label":"Source of Income","options":["Salaried","Business","IT Returns","3mths Payslip","Annual Income (in Rs.)"],"required":null,"pdf_field":""},{"help":"If PAN number is not available submit Form 60","type":"text","label":"PAN Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"GST Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Residential Status","options":["Indian Resident","NRI","PIO","Foreign National"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"CKYC Number","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"PEP means individuals with prominent public functions or their relatives","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":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Include Address line 1, City/Town/Village, District, State, Country and Pincode","type":"text","label":"Current Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Include Address line 1, City/Town/Village, District, State, Country and Pincode","type":"text","label":"Permanent Address (should be same as address Proof)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Alternate Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Attach one valid government ID proof","type":"choice","label":"Please attach any one proof in support of ID and Address","options":["Voter ID","Driving License (with Expiry Date)","Aadhar Card","Passport (with Expiry Date)","NREGA Job Card","Any Other Govt. Notified Document"],"required":true,"pdf_field":""},{"help":"Fill Annexure to Proposal Form (Nomination Form) if multiple nominees","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you wish to receive the physical copy of the policy document","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Business Type","options":[],"required":false,"pdf_field":""},{"help":"Includes unorganised sector, informal sector, economically vulnerable or backward classes, and other categories","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you a ASHA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you a MGNREGA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Yes (please tick)","options":["Unorganized Sector","Economically Vulnerable or Backward Classes","Other Categories of Persons","Informal Sector"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Please choose the Policy Term Opted","options":["1 yr","2 yrs","3 yrs"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Appointee (if nominee is a minor)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If you already have an e-Insurance Account (eIA) number, please provide","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you want to pay the premium in Instalments","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If yes (Please choose Instalment option)","options":["Quarterly","Halfyearly"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"SM CODE","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"SM NAME","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"AGENT / CORPORATE AGENT / BROKER / IMF / POSP / CODE","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"AGENT / CORPORATE AGENT / BROKER / IMF / POSP / NAME","options":[],"required":false,"pdf_field":""},{"help":"Same as KYC/ID proof","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Same as KYC/ID proof","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Father / Spouse Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"POSP PAN NUMBER","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"POSP GST NUMBER","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Other Proof, please specify","options":[],"required":false,"pdf_field":""},{"help":"Provide occupation details","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Specify proof like IT Returns, Payslip etc.","type":"text","label":"Proof of Income to be submitted","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the person/s proposed for Insurance","fields":[{"help":"For each insured person","type":"date","label":"Date of Birth (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (cms)","options":[],"required":false,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight (kgs)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you want Gold Plan [Applicable for Medi classic Insurance Policy (Individual)]","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Applicable for Young Star Insurance Policy - Plan Opted for Individual","options":["Silver","Gold"],"required":false,"pdf_field":""},{"help":"Refer brochure for available sum insured options","type":"amount","label":"Sum Insured Opted (For Individual Policy) (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Choose aggregate deductible if Section II is opted","type":"choice","label":"Applicable for Star Extra Protect - Add On Cover - If you opted Section II Choose the Aggregate Deductible","options":["Section – I","Section – II","Rs.25,000/-","Rs.50,000/-","Rs.1,00,000/-"],"required":false,"pdf_field":""},{"help":"Patient Care add-on is available only for Insured Persons above 60yrs of age","type":"checkbox","label":"Add-ons : [Applicable for Medi classic Insurance Policy (Individual)] - Do you want add on covers - If Yes, Please tick (ü)","options":["Hospital Cash","Patient Care"],"required":false,"pdf_field":""},{"help":"Columns: Name of the Insurance Company, Period of Insurance, Sum Insured (Rs), Policy No.","type":"table","label":"Existing Insurance Coverage with us and/or any other company give details","options":[],"required":false,"pdf_field":""},{"help":"Columns: Ailment for which Claim was made, Year (YYYY), Claim Amount Paid / Rejected","type":"table","label":"Details of Claims","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever been declined health insurance coverage due to a diagnosis of a health condition?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide detailed medical history; a dash is not sufficient","type":"text","label":"Health History: Please provide detailed, response-specific diagnosis and treatment","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questions","fields":[{"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":"","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":"","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":"","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":"Provide diagnosis, duration, medication and treatment details for listed diseases","type":"text","label":"5. Has the person proposed for insurance ever suffered or suffering from any of the following (a to r)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"6. Has the person proposed for insurance (a) Undergone any medical test? (b) Prescribed any medicines? (c) Been advised for any surgery/treatment? (d) Received / receiving any payment for any disability / injury / illness / diseases. Give details","options":[],"required":true,"pdf_field":""},{"help":"","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":"","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":"","type":"text","label":"9. Type and the total number of medical documents provided","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Applicable for STAR COMPREHENSIVE INSURANCE POLICY - Buy back PED (Optional Cover) required?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Insured's Occupation require to engage in manual labour?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","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":"Sum insured for personal accidental cover equals sum insured opted for health cover","type":"text","label":"Name of the family member chosen for Personal Accident Insurance under Section-10","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer","fields":[{"help":"","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Branch","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque leaf","type":"text","label":"Payment Details (Please attach a photo copy of cancelled cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Cash payments are not eligible for the 80D tax benefits","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","NEFT","ECS","Cash"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the person who explained","options":[],"required":false,"pdf_field":""},{"help":"Agent confirms product suitability and information correctness","type":"signature","label":"Declaration of the Agent / Intermediary","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent code","type":"text","label":"Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent"}],"deadlines":["Contact the office if policy is not received within 15 days from the date of payment of premium"],"applies_to":"Star Comprehensive Insurance Policy and other related health insurance products as listed in the form","attachments":["Copy of PAN card or Form 60","Proof of ID and Address (one of Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card, Any Other Govt. Notified Document)","Cancelled cheque leaf (photo copy)","Annexure to Proposal Form (Nomination Form) if multiple nominees","Medical documents as applicable"],"declarations":["The proposer declares that all information given is true and complete to the best of their knowledge","The policy will come into force only after full payment of premium and acceptance of the proposal","The proposer will notify any change in occupation or health before risk acceptance","The company may seek medical information from doctors, hospitals, employers, and insurers for underwriting and claims","The company may share and seek information including medical records for underwriting and claims with government and regulatory authorities","Payment is made from the proposer's own bank account and source of funds is legal; no third-party payments allowed","The proposer authorizes the company to contact them for service-related purposes overriding NCPR","Concealment, misdeclaration or non-disclosure will render the policy void ab-initio and claims will be denied","The company reserves the right to not renew the policy in case of fraud or misrepresentation","The proposer consents to the company’s privacy policy and agrees to professional conduct in communications","The company is authorized to deduct premium from the given bank account"],"dropped_labels":19},"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/4992-common-proposal-form-1"}