{"id":4998,"title":"Star Critical Illness Multipay 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_Critical_Illness_Multipay_Insurance_Policy_V_5_Web_d7eb94ae57.pdf","sha256":"c61da92e8d82cbc5eaae6f6cc5dc88da313932c2bae0e0be3c897882645a9a37","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the proposer to apply for the Star Critical Illness Multipay Insurance Policy by providing personal, nominee, and health details.","notes":["Fill the form in block letters.","Attach original or valid proofs as specified.","Use the Annexure to Proposal Form for multiple nominees.","Cash payments are not eligible for 80D tax benefits.","Beware of fraudulent calls and do not share sensitive information.","Policy can be issued only if earning member is also covered.","Sum insured for non-earning members should not exceed that of earning members."],"title":"Star Critical Illness Multipay 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":true,"pdf_field":""},{"help":"PEP means Politically Exposed Person","type":"yes-no","label":"Are you (Proposer) or any of the insured person is a PEP","options":["No","Yes"],"required":true,"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":"Enter mobile number","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":"Optional alternate mobile number","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":"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":null,"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":"Provide 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":"","type":"yes-no","label":"Do you want to pay the premium in Instalments","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Choose instalment frequency if paying in instalments","type":"choice","label":"If yes (Please choose Instalment option)","options":["Quarterly","Halfyearly"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Prefix","options":["Mr.","Mrs.","Ms."],"required":false,"pdf_field":""},{"help":"Proposer's first name","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"Proposer's middle name","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Proposer's last name","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":"Sign or put thumb impression","type":"signature","label":"Signature / Thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Source of Income","options":["Salaried","Business"],"required":true,"pdf_field":""},{"help":"Attach if applicable","type":"text","label":"IT Returns","options":[],"required":false,"pdf_field":""},{"help":"Attach if applicable","type":"text","label":"3mths Payslip","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"If PAN 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":"text","label":"CKYC Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Other Proof, please specify","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Proof of Income to be submitted","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Person Proposed for Insurance","fields":[{"help":"Name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Gender of each insured person","type":"choice","label":"Gender","options":["M","F","Transgender"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","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":true,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"If available","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured for each insured person","type":"amount","label":"Sum Insured Opted (Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Columns: 1. Name of the Insurance Company and Policy No., 2. Period of Insurance, 3. Sum Insured (Rs)","type":"table","label":"Existing Insurance Coverage with us and/or any other company give details","options":[],"required":false,"pdf_field":""},{"help":"Columns: 1. Ailment for which Claim was made, Year, 2. 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":["No","Yes"],"required":true,"pdf_field":""},{"help":"Provide detailed health history; a dash is not sufficient","type":"text","label":"Health History: Please provide answer in detail, specific diagnosis and treatment details","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""},{"help":"Answer each condition with details of diagnosis and treatment","type":"text","label":"Has the person proposed for insurance ever suffered or suffering from any of the following (a-k)","options":[],"required":true,"pdf_field":""},{"help":"Specify details for tobacco chewing, smoking, alcohol consumption","type":"text","label":"Does the person proposed for insurance has any of the mentioned habits (a-d)","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any application for insurance on proposed life been postponed, declined, rejected, accepted with special terms or accepted with extra premium?","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"Include exposure to hazardous materials or dangerous hobbies","type":"text","label":"Please provide details, if any, regarding occupation or business which may render you susceptible to injury or illness","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the person proposed for insurance undergone or recommended to undergo any hospitalization, operation / surgery or any other investigations (excluding check ups for employment / insurance / foreign visit)?","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the person proposed for insurance ever been tested positive for HIV/AIDS or been tested/treated for other sexually transmitted disease or awaiting the results of such a test?","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are any of your family members suffering from/have suffered from/have died of Heart Disease or High Blood Pressure or Stroke or Diabetes or Kidney disease or Cancer or HIV/AIDS?","options":["No","Yes"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Type and total number of medical documents provided","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer","fields":[{"help":"Specify account type","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"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":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Date of filling bank details","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Premium amount to be paid","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Branch where payment is made","type":"text","label":"Payment Details Branch","options":[],"required":false,"pdf_field":""},{"help":"Attach photocopy of cancelled cheque leaf","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Cash payments are not eligible for 80D tax benefits","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","ECS","CC Mandate","Cash","NEFT"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Declaration","fields":[{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent 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 Critical Illness Multipay Insurance Policy","attachments":["One proof in support of ID and Address (Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card)","Copy of PAN card or Form 60","Photograph of Proposer (passport size)","Photograph of each Insured Person (stamp size)","Photocopy of cancelled cheque leaf"],"declarations":["The proposer declares all information 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 proposal.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and insurance information for underwriting and claims.","The proposer consents to electronic communication and sharing of information for servicing.","Concealment or misrepresentation will void the policy and claims.","The company may not renew the policy in case of fraud or non-disclosure.","The proposer consents to premium deduction from the given bank account."],"dropped_labels":14},"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/4998-star-critical-illness-multipay-insurance-policy-proposal-form"}