{"id":4993,"title":"Star Out Patient Care Insurance Policy","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/3_Proposal_Form_Star_Out_Patient_Care_Insurance_Policy_V_11_Web_866d693413.pdf","sha256":"9c196484bf49fae8f5c68348ffa1297ee32a5ee4608c402f3168658bdbedff7a","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is a proposal form to apply for the Star Out Patient Care Insurance Policy. It is filled by the proposer who wishes to purchase the insurance.","notes":["Fill the form in block letters.","Attach original or valid proofs as specified.","Cash payments are not eligible for 80D tax benefits.","Beware of fraudulent calls or emails asking for personal information.","Use separate sheet if additional space is needed for health details.","Multiple policies exceeding maximum sum insured may be cancelled.","The proposal form and product features have been explained and understood."],"title":"Star Out Patient Care Insurance Policy","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":"If yes, provide details","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":"Fill address line 1, city/town/village, district, state, country and pincode","type":"text","label":"Current Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Fill address line 1, city/town/village, district, state, country and pincode","type":"text","label":"Permanent Address (should be same as address Proof)","options":[],"required":null,"pdf_field":""},{"help":"","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 (with Exp Dt.)","Aadhar Card","Passport (with Exp Dt.)","NREGA Job Card"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"If multiple nominees, attach separate nomination form specifying % share","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":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"choice","label":"Business Type","options":["Unorganized Sector","Economically Vulnerable or Backward Classes","Other Categories of Persons","Informal Sector"],"required":null,"pdf_field":""},{"help":"Includes unorganised, informal sectors, economically vulnerable or backward classes","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you a ASHA worker","options":["No","Yes"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you a MGNREGA worker","options":["No","Yes"],"required":null,"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":null,"pdf_field":""},{"help":"Provide existing eIA number if any","type":"text","label":"If you already have an e-Insurance Account (eIA) number, please provide","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Prefix","options":["Mr.","Mrs.","Ms."],"required":null,"pdf_field":""},{"help":"Fill in block letters","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature / Thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Premium amount paid","type":"amount","label":"Payment of Rs.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan and Bank Details","fields":[{"help":"Select one plan type","type":"choice","label":"Plan Type (Please tick)","options":["Silver Plan","Gold Plan","Platinum Plan"],"required":true,"pdf_field":""},{"help":"Number of family members to be insured","type":"number","label":"Family Size","options":[],"required":true,"pdf_field":""},{"help":"Fill bank name, branch, IFSC code, account number and type","type":"text","label":"Bank Details of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque copy for bank verification","type":"attachment","label":"Please attach a photo copy of cancelled cheque leaf","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount in lakhs","type":"amount","label":"Sum Insured on Floater Basis in Lakhs","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment (Cash payments 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":"Provide cheque or DD number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Date of filling form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Person Proposed for Insurance","fields":[{"help":"","type":"yes-no","label":"Have you ever been declined health insurance coverage due to a diagnosis of a health condition?","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent or intermediary code","type":"text","label":"Code","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"}],"deadlines":["Contact the office if policy is not received within 15 days from the date of payment of premium"],"applies_to":"Star Out Patient Care Insurance Policy","attachments":["One proof in support of ID and Address (Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card)","Annexure to Proposal Form (Nomination Form)","Photo copy of cancelled cheque leaf","Passport size photograph of the Proposer","Stamp size photographs of Insured Persons","Insurance Agent’s Confidential Report (if any)","Separate sheet for additional health details if needed"],"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, or insurers for underwriting and claims.","The company may share and seek information with government and regulatory authorities for underwriting and claims.","Payment is made from the proposer’s own bank account and source of funds is legal; no third-party payments allowed.","The proposer consents to receive communications from the company and agrees to electronic delivery of documents.","Concealment, misdeclaration or non-disclosure will render the policy void 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 premium deduction from the given bank account."],"dropped_labels":17},"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/4993-star-out-patient-care-insurance-policy"}