{"id":5000,"title":"Super Star Proposal Form (Individual)","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Super_Star_Proposal_Form_1_Individual_V1_02_12_24_3c6a6cf021.pdf","sha256":"78a1912597095875893a8390bb673313bf96a10bd0510984ee97b381c05a707e","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals proposing to purchase a health insurance policy from Star Health and Allied Insurance Company Limited. The proposer fills it to provide personal, health, and payment details for underwriting and policy issuance.","notes":["Fill the form in block letters.","Attach passport size photograph of proposer and stamp size photographs of insured persons.","Attach proof of ID and address as specified.","Attach Annexure to Proposal Form for nomination details.","Cash payments are not eligible for 80D tax benefits.","Beware of fraudulent calls and do not share personal or payment information over phone or email.","Disclose all existing health insurance policies to avoid cancellation.","Use original and valid documents for KYC and health declarations.","If proposer is illiterate or signs in a different language, the details must be explained and confirmed by a witness."],"title":"Super Star Proposal Form (Individual)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Acknowledgement and Proposer Details","fields":[{"help":"Fill policy name, proposer name, payment amount, payment mode, cheque/DD number, date and bank name","type":"text","label":"Received the proposal for ___________________________________________________________________________________________ policy from Mr/ Mrs/ Ms.__________________________________________________________________ along with payment of Rs._________________/- by Cash / vide Cheque/ DD No. ___________________________dt._________________________ drawn on _____________________________.","options":[],"required":null,"pdf_field":""},{"help":"Date of proposal submission","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of proposal submission","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Name and code of the person receiving the proposal","type":"text","label":"Name & Code of the authorised person","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of proposer or insured person","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender of proposer or insured person","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Select source of income","type":"choice","label":"Source of Income","options":["Salaried","Business","IT Returns","3mths Payslip"],"required":true,"pdf_field":""},{"help":"Enter annual income in rupees","type":"amount","label":"Annual Income (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number; if not available submit Form 60","type":"text","label":"PAN Number","options":[],"required":true,"pdf_field":""},{"help":"Enter GST number if applicable","type":"text","label":"GST Number","options":[],"required":false,"pdf_field":""},{"help":"Select residential status","type":"choice","label":"Residential Status","options":["Indian Resident","NRI","PIO","Foreign National"],"required":true,"pdf_field":""},{"help":"Indicate if CKYC number is available","type":"choice","label":"CKYC Number","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select if proposer or insured is a politically exposed person","type":"choice","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":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter current address line 1","type":"text","label":"Current Address - Address line 1","options":[],"required":true,"pdf_field":""},{"help":"Enter city, town or village","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter country and postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address line 1","type":"text","label":"Permanent Address (should be same as address Proof) - Address line 1","options":[],"required":true,"pdf_field":""},{"help":"Enter city, town or village","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter country and postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter alternate mobile number if any","type":"phone","label":"Alternate Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Attach one valid government 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","Any Other Govt. Notified Document"],"required":true,"pdf_field":""},{"help":"Enter nominee's full name","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee to proposer","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship of nominee to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Select if you want a physical policy document","type":"choice","label":"Do you wish to receive the physical copy of the policy document","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select insurance repository if no e-Insurance Account number","type":"choice","label":"If you don’t have an (elA) number, please choose any one Insurance Repository","options":["Karvy Insurance Repository Limited","CDSL Insurance Repository Limited","CAMS Insurance Repository Services Limited","NSDL National Insurance Repository (NIR)"],"required":false,"pdf_field":""},{"help":"Select if you want to update CKYC","type":"choice","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"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":"Enter 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":"Enter business type","type":"text","label":"Business Type","options":[],"required":false,"pdf_field":""},{"help":"Select if you belong to social sector classification","type":"choice","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select if you are an ASHA worker","type":"choice","label":"Are you a ASHA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select if you are a MGNREGA worker","type":"choice","label":"Are you a MGNREGA worker","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Tick applicable social sector category","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":"Select policy term","type":"choice","label":"Please choose the Policy Term","options":["1yr","2yr","3yr","4yr","5yr"],"required":true,"pdf_field":""},{"help":"Select if you want to pay premium in instalments","type":"choice","label":"Do you want to pay the premium in Instalments","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select instalment frequency","type":"choice","label":"If yes (Please choose Instalment option)","options":["Quarterly","Halfyearly"],"required":false,"pdf_field":""},{"help":"Enter sales manager code","type":"text","label":"SM CODE","options":[],"required":false,"pdf_field":""},{"help":"Enter sales manager name","type":"text","label":"SM NAME","options":[],"required":false,"pdf_field":""},{"help":"Enter agent or broker code","type":"text","label":"AGENT / CORPORATE AGENT / BROKER / IMF / POSP / CODE","options":[],"required":false,"pdf_field":""},{"help":"Enter agent or broker name","type":"text","label":"AGENT / CORPORATE AGENT / BROKER / IMF / POSP / NAME","options":[],"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","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 name","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"Sign or thumb impression of proposer","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","type":"date","label":"Date","options":[],"required":true,"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","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 account type","type":"choice","label":"Type of Account","options":["Current Account","Savings Account"],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque copy","type":"attachment","label":"Payment Details (Please attach a photo copy of cancelled cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque or demand draft number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","NEFT","ECS","Cash","CC Mandate","Others"],"required":true,"pdf_field":""},{"help":"Specify other payment mode if selected","type":"text","label":"Others, Please Specify","options":[],"required":false,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the person/s proposed for Insurance","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Have you ever been declined health insurance coverage due to a diagnosis of a health condition?","options":[],"required":true,"pdf_field":""},{"help":"Provide detailed health 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":"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":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Sign or thumb impression to confirm declaration","type":"signature","label":"Signature / Thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of signing declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of person explaining the proposal form","type":"text","label":"Name of the person who explained","options":[],"required":false,"pdf_field":""},{"help":"Signature of person explaining the form","type":"signature","label":"Signature of the person who explained","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":["Contact office if policy is not received within 15 days from the date of payment of premium"],"applies_to":"Individual health insurance proposals","attachments":["Photo copy of cancelled cheque leaf","Proof of ID and Address (one of Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card, Any Other Govt. Notified Document)","Annexure to Proposal Form (Nomination Form)","Insurance Agent’s Confidential Report (if any)","Medical documents as required for health history"],"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 for underwriting and claims with government and regulatory authorities and healthcare providers.","Payment is made from 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 the privacy policy.","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 authorizes premium deduction 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/5000-super-star-proposal-form-individual"}