{"id":4999,"title":"Special Care Gold, Star Health and Allied Insurance Company Limited","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Proposal_Form_Special_Care_Gold_V_5_Web_c4868d86cd.pdf","sha256":"b96f4dd666490d7baa2c2c0454b60e14c5e9f0d2d20c4a4168822eb96373cf86","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer applying for the Special Care Gold policy from Star Health and Allied Insurance Company Limited.","notes":["Fill the form in block letters.","Only one policy is allowed per person.","Cash payments are not eligible for 80D tax benefits.","Attach original or valid proofs as specified.","Beware of fraudulent calls or emails asking for personal information.","If nominee is minor, provide appointee details.","If additional space is needed for medical details, enclose a separate sheet.","PAN card copy or Form 60 is mandatory; if CKYC number is provided, proof submission is not mandatory."],"title":"Special Care Gold, Star Health and Allied Insurance Company Limited","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Declaration","fields":[{"help":"","type":"text","label":"Proposal Form No.:","options":[],"required":null,"pdf_field":""},{"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":"Select Yes if proposer or insured person is a politically exposed person or related","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":"Fill full current address including Address line 1, City/Town/Village, District, State, Country and Pincode","type":"text","label":"Current Address","options":[],"required":true,"pdf_field":""},{"help":"Enter valid mobile number","type":"phone","label":"Mobile Number","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 from the options","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 full name of nominee","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship of nominee to proposer","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship of nominee to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Select Yes to receive physical policy document, No for electronic copy","type":"yes-no","label":"Do you wish to receive the physical copy of the policy document","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes to update CKYC with provided KYC details","type":"yes-no","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Specify your business type","type":"text","label":"Business Type","options":[],"required":false,"pdf_field":""},{"help":"Select Yes if you belong to any social sector classification listed","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select Yes if you are an ASHA worker","type":"yes-no","label":"Are you a ASHA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select Yes if you are a MGNREGA worker","type":"yes-no","label":"Are you a MGNREGA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Tick the applicable social sector classification 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":false,"pdf_field":""},{"help":"Enter name of appointee if nominee is minor","type":"text","label":"Name of the Appointee (if nominee is a minor)","options":[],"required":false,"pdf_field":""},{"help":"Select Yes to receive policy documents via insurance repository","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":"Enter your existing e-Insurance Account number","type":"text","label":"If you already have an e-Insurance Account (eIA) number, please provide","options":[],"required":false,"pdf_field":""},{"help":"Select Yes to pay premium in instalments","type":"yes-no","label":"Do you want to pay the premium in Instalments","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select instalment frequency if paying in instalments","type":"choice","label":"If yes (Please choose Instalment option)","options":["Quarterly","Halfyearly"],"required":false,"pdf_field":""},{"help":"Enter first name of proposer","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"Enter middle name of proposer if any","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Enter last name of proposer","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":"Enter additional address details","type":"text","label":"Address line 2","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":"Name of person who explained the proposal form","type":"text","label":"Name of the person who explained","options":[],"required":false,"pdf_field":""},{"help":"Signature of person who explained the form","type":"signature","label":"Signature of the person who explained","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer","fields":[{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Name of the Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Select type of bank account","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":true,"pdf_field":""},{"help":"Specify if account type is Others","type":"text","label":"Others Please Specify","options":[],"required":false,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque leaf photocopy","type":"attachment","label":"Please attach a photo copy of cancelled cheque leaf","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","NEFT","ECS","Cash"],"required":true,"pdf_field":""},{"help":"Enter bank branch for cheque/DD","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque or demand draft number","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Sum Insured Options and Insured Person Details","fields":[{"help":"Enter full name of insured person","type":"text","label":"Insured Person - 1 Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["M","F","Transgender"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter height in centimeters","type":"number","label":"Height (cms)","options":[],"required":false,"pdf_field":""},{"help":"Enter weight in kilograms","type":"number","label":"Weight (kgs)","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Enter annual income in rupees","type":"amount","label":"Annual Income (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number if available","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured Opted (For Individual Policy) (Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Provide details of existing insurance coverage if any","type":"text","label":"Existing “Person with Disability or HIV/AIDS” Insurance Coverage with us and/or any other company give details","options":[],"required":false,"pdf_field":""},{"help":"Enter family physician's name","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""},{"help":"Enter family physician's phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Enter family physician's registration number","type":"text","label":"Regn No","options":[],"required":false,"pdf_field":""},{"help":"Select if waiver of co-payment is opted","type":"yes-no","label":"Waiver of Co-payment Opted","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"Enter date of declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"Special Care Gold health insurance policy","attachments":["Photograph of Insured Person","Photograph of Proposer","Proof of ID and Address (one from Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card)","Annexure to Proposal Form (Nomination Form)","Photocopy of cancelled cheque leaf"],"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 proposal by the insurer.","The proposer will notify any change in occupation or health before risk acceptance.","The insurer is authorized to seek medical and insurance information for underwriting and claim settlement.","The proposer consents to sharing of information with governmental and regulatory authorities and service providers.","Concealment, misdeclaration or non-disclosure will render the policy void and claims will be denied.","The insurer 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 and confirms source of funds is legal.","The proposer agrees to receive communications electronically and consents to the company’s privacy policy.","The proposer agrees to maintain professional conduct in communications with the insurer."],"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/4999-special-care-gold-star-health-and-allied-insurance-company-limited"}