{"id":4994,"title":"Arogya Sanjeevani Policy, Star Health And Allied Insurance Co Ltd.","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_Arogya_Sanjeevani_Insurance_Policy_V_11_accc24e007.pdf","sha256":"94717964cf31cd594bc2d14d2061c4c3c00dbb589a615ca311282bff1ddd6aa5","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer seeking insurance coverage under the Arogya Sanjeevani Policy.","notes":["Use original and complete information; non-disclosure may lead to claim repudiation or policy cancellation.","Affix stamp size photographs of all insured persons as indicated.","Beware of fraudulent calls or emails asking for personal or payment information.","Insurance is a contract of utmost good faith; answer all questions honestly and completely.","No third-party payments are allowed for premium.","The proposer must sign or provide thumb impression; if illiterate, the form must be explained and signed by the explainer.","Prohibition of rebates as per Section 41 of Insurance Act 1938 applies.","The cash/cheque given is banked for operational convenience and does not mean acceptance of risk."],"title":"Arogya Sanjeevani Policy, Star Health And Allied Insurance Co Ltd.","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Insurance Details and Previous Coverage","fields":[{"help":"Provide the name of the insurance company and policy number of existing coverage, if any.","type":"text","label":"Name of the Insurance Company and Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Disclose all health insurance policies covering the lives proposed for insurance.","type":"text","label":"Existing Insurance coverage with us and/or any other company, give details","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health History and Medical Details","fields":[{"help":"Provide details if applicable.","type":"text","label":"Disease of bones/joints, slipped disc, spinal disorder, injury to ligaments - if yes, mention duration/date of diagnosis and operation or treatment details","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis and treatment details if applicable.","type":"text","label":"Whether diagnosed to have arthritis (Rheumatoid / Osteo arthritis or any other inflammatory arthritis like Ankylosing spondylitis). If yes, mention treatment details and submit all records","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Gynecological disorder such as menstrual irregularity (DUB), fibroid uterus, ovarian cyst- or have undergone cesarean / hysterectomy - if yes, mention duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Disease of stomach, intestine, liver, gall bladder / Pancreas, Piles / Fistula / Fissure / Hernia if yes, mention duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Disease of kidney, urinary bladder, urinary tract disease, Calculi- if yes, duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Disease of prostate / hydrocele / genital disease / - if yes, mention duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Diseases of the eye, Cataract / corneal / retinal, other disorders and Ear, Nose Throat disease -if yes, mention duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Cancer, Precancerous lesions, Non-healing ulcers - if yes, mention type of cancer, duration/date of diagnosis and treatment details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Any blood disorder, specify the diagnosis, mention duration/date of diagnosis and medication details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Any autoimmune disease / any long-term steroid Immunosuppressant intake like myasthenia gravis / SLE / Psoriasis, Ulcerative Colitis, Crohn's disease etc.) duration/date of diagnosis and medication details.","options":[],"required":null,"pdf_field":""},{"help":"Specify any other health problems or diseases.","type":"text","label":"Any other Health problems/diseases please specify","options":[],"required":null,"pdf_field":""},{"help":"Provide illness name, medicine details, and duration if medicines prescribed.","type":"text","label":"Prescribed any medicines? If yes: 1. Name the illness for which medicines have been prescribed 2. Details of medicines and drugs prescribed 3. Period for which these drugs were taken","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any advised surgery or treatment.","type":"text","label":"Been advised for any surgery/treatment? - If yes, give details","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable.","type":"text","label":"Received / receiving any payment for any disability / injury / illness / diseases. Give details","options":[],"required":null,"pdf_field":""},{"help":"Provide habit details and related health complications if any.","type":"text","label":"Does the person proposed for insurance has any of the mentioned habits: a) Chew Tobacco - If yes, since when b) Smoke - If yes, since when c) Consume Alcohol - If yes, since when d) If a, b and c, are mentioned as yes, mandatory to give details whether diagnosed with any local or systemic disease / complications.","options":[],"required":null,"pdf_field":""},{"help":"Provide diagnosis details and attach proof.","type":"text","label":"Is the person proposed for insurance positive for HIV, Hepatitis B/C If yes, mention duration/date of diagnosis, medication details, CD4 count (please attach proof) and Viral load","options":[],"required":null,"pdf_field":""},{"help":"Specify types and count of medical documents submitted.","type":"text","label":"Type and the total number of medical documents provided","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Agent or intermediary code.","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"Full name of the agent or intermediary.","type":"text","label":"Name of the Agent / Specified Person of Corporate Agent / Broker / Qualified Person / Insurance Sales Person of the IMF / POSP / Micro Agent","options":[],"required":null,"pdf_field":""},{"help":"Signature of the agent or intermediary.","type":"signature","label":"Signature of the Agent / Specified Person of Corporate Agent / Broker / Qualified Person / Insurance Sales Person of the IMF / POSP / Micro Agent","options":[],"required":null,"pdf_field":""}],"filled_by":"agent / intermediary"},{"title":"Acknowledgement","fields":[{"help":"Name of proposer.","type":"text","label":"Received the proposal for policy from Mr/ Mrs/ Ms.","options":[],"required":null,"pdf_field":""},{"help":"Amount paid and mode of payment with cheque/DD details.","type":"amount","label":"along with payment of Rs. /- by Cash / vide Cheque/ DD No.","options":[],"required":null,"pdf_field":""},{"help":"Date of cheque/DD.","type":"date","label":"dt.","options":[],"required":null,"pdf_field":""},{"help":"Bank name on which cheque/DD is drawn.","type":"text","label":"drawn on","options":[],"required":null,"pdf_field":""},{"help":"Date of acknowledgement.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of acknowledgement.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Name and code of the authorized person acknowledging receipt.","type":"text","label":"Name & Code of the authorised person","options":[],"required":null,"pdf_field":""},{"help":"Signature of the authorized person.","type":"signature","label":"Signature of the authorised person","options":[],"required":null,"pdf_field":""}],"filled_by":"insurance company authorized person"},{"title":"Proposer Declaration and Consent","fields":[{"help":"Place where the declaration is signed.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the declaration.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of the proposer signing the declaration.","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Details of payment made with proposal submission.","type":"text","label":"Submitted the above proposal for policy along with payment of Rs. by cash/vide cheque/DD no. dated drawn on","options":[],"required":null,"pdf_field":""},{"help":"Name and signature of the person who explained the form to the proposer.","type":"text","label":"Where the proposer is illiterate or signs in a language different from that of the language of the proposal form. I hereby confirm that the details have been explained to the proposer","options":[],"required":null,"pdf_field":""},{"help":"Date of explanation.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of the person who explained the form.","type":"text","label":"Name of the person who explained","options":[],"required":null,"pdf_field":""},{"help":"Signature of the person who explained the form.","type":"signature","label":"Signature of the person who explained","options":[],"required":null,"pdf_field":""},{"help":"Confirm understanding of the proposal form and product features.","type":"checkbox","label":"The contents of the proposal form and features of the product have been fully explained to me and I have fully understood the significance of the proposed contract.","options":["I agree"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["Contact our office in case policy is not received within 15 days from the date of payment of premium."],"applies_to":"Arogya Sanjeevani health insurance policy","attachments":["Insurance Agent's Confidential Report, If Any","Proof of CD4 count for HIV positive persons"],"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 after submission but before 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 confirmed to be 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 insurer and agrees to electronic delivery of policy documents.","Concealment, misdeclaration or non-disclosure will render the policy void ab-initio and claims will not be payable.","The insurer reserves the right to not renew the policy in case of fraud or misrepresentation.","The proposer consents to the insurer's privacy policy and agrees to professional conduct standards in communications.","The proposer authorizes premium deduction from the given bank account."],"dropped_labels":8},"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/4994-arogya-sanjeevani-policy-star-health-and-allied-insurance-co-ltd"}