{"id":5002,"title":"PA Common Proposal Form","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/PA_Common_Proposal_Form_V_5_Web_27a4da8bb8.pdf","sha256":"509cafcc9a7afa005c6fd9254c56de3ca331a4b7700ccd9fc7b941c4b3e8b3a1","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals (proposers) to apply for Accident Care Individual Insurance Policy and related accident insurance policies offered by Star Health and Allied Insurance Company Limited.","notes":["Fill the form in block letters.","Attach original or valid documents as proof; photocopies may be required.","Nomination form annexure is mandatory.","Use the exact format for dates (DD/MM/YYYY).","Cash payments are not eligible for 80D tax benefits.","Beware of fraudulent calls or emails asking for personal or payment information.","If proposer is illiterate or signs in a different language, details must be explained and confirmed.","The proposal form and product features must be fully understood before signing."],"title":"PA Common 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":"","type":"text","label":"Current Address Address line 1","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Include postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter 10-digit mobile number","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Permanent Address (should be same as address Proof) Address line 1","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Include postal code","type":"text","label":"Country and Pincode","options":[],"required":true,"pdf_field":""},{"help":"Optional alternate contact 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 Exp Dt.:","Aadhar Card","Passport Exp Dt.:","NREGA Job Card"],"required":true,"pdf_field":""},{"help":"Name of nominee for the policy","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Relationship of proposer to nominee","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Choose Yes or No","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 one 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":"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":"Consent to receive policy documents electronically","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 existing 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":"Specify business type","type":"text","label":"Business Type","options":[],"required":null,"pdf_field":""},{"help":"Select Yes if applicable","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":true,"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":"Tick applicable social sector classification","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 Opted","options":["1 yr","2 yrs","3 yrs"],"required":true,"pdf_field":""},{"help":"Select prefix for proposer name","type":"choice","label":"Prefix","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Proposer's first name as per KYC/ID proof","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 as per KYC/ID proof","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"Name of father or spouse","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"Name of mother","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Specify occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Select source of income","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":"Enter annual income in rupees","type":"amount","label":"Annual Income (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Provide PAN number or submit Form 60 if not available","type":"text","label":"PAN Number","options":[],"required":true,"pdf_field":""},{"help":"Provide 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":"Provide CKYC number if available","type":"text","label":"CKYC Number","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select Yes or No","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":"Select Yes or No","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 other proof if applicable","type":"text","label":"Other Proof, please specify","options":[],"required":false,"pdf_field":""},{"help":"Specify proof of income documents","type":"text","label":"Proof of Income to be submitted","options":[],"required":false,"pdf_field":""},{"help":"Provide email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the person proposed for insurance","fields":[{"help":"Enter date of birth for each insured person","type":"date","label":"Date of Birth (DD/MM/YYYY)","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":"Specify occupation or trade","type":"text","label":"Occupation/Trade/Business","options":[],"required":true,"pdf_field":""},{"help":"Provide ABHA number if available","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"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":"Select Yes or No for each insured person","type":"yes-no","label":"I declare that none of the proposed insured members, including myself, have been diagnosed with or treated for any of the following: heart disease, stroke, cancer, neurological disorders (such as epilepsy or paralysis), chronic lung disease, kidney or liver diseases, severe mental health conditions, autoimmune disorders, HIV/AIDS, Genetic disorders, or any physical disability or chronic illness. (Kindly Specify Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Does the occupation of the proposed persons require engaging in manual labour","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if Yes","type":"text","label":"Does the proposed person engage in or propose to engage in racing on wheels or horse back, Big Game Hunting, Mountaineering, winter sports, skiing or ice Hockey, Ballooning, Polo or sports of similar nature or any other activities of similar nature. If yes give details","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Has/Is the proposed person suffered/ suffering from Physical defect or infirmity or any other disability. If yes give details.","options":[],"required":false,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Has the person ever proposed for any personal accident insurance including Star Health and Allied Insurance Company Limited.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, provide details of Insurance Company | Period of Insurance | Sum Insured.","options":[],"required":false,"pdf_field":""},{"help":"Answer if applicable","type":"yes-no","label":"Has any company Declined to issue a policy or Imposed any restrictions / special conditions","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Has the proposed person ever claimed or received compensation under any Accident Policy? If yes, give full details","options":[],"required":false,"pdf_field":""},{"help":"Provide monthly income in rupees","type":"amount","label":"What is the monthly income from Gainful Employment (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured person","type":"yes-no","label":"Medical Expenses Extension (Optional Benefit)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured person","type":"yes-no","label":"Hospital Cash (Optional Benefit)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured person","type":"yes-no","label":"Home convalescence (Optional Benefit)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured person","type":"yes-no","label":"Winter Sports/Rallies (Optional Cover)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured person","type":"yes-no","label":"Do you wish to cover Accidents at work place?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If Yes, please furnish details of nature of work and location of the workplace","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Please furnish details of other similar insurance/s taken","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Any proposal for this insurance or any other such insurance refused, cancelled or higher premium charged. If so provide details","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Has any claim been rejected by the previous Insurer? If Yes, please provide details","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"In last 3 years have any of these persons who proposed for insurance: i) Has any life / Health / disability / cover declined / modified / postponed ii) Been advised to surgery but not yet done iii) Received payment for disability / illness / injury iv) Been treated as inpatient or out patient for surgery v) Had any medical treatment, mental or physical impairment","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer","fields":[{"help":"Provide 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":"Provide bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Provide branch name","type":"text","label":"Name of the Branch","options":[],"required":true,"pdf_field":""},{"help":"Provide IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque copy","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":"Provide branch name if applicable","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Provide cheque or demand draft number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Read and agree to the declaration statements","type":"text","label":"Declaration","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":"Print name of proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"Date of agent declaration","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":"Accident Care Individual Insurance Policy, POS Accident Care Individual Insurance Policy, Family Accident Care Insurance Policy, Accident Trauma Care Insurance Policy (Individual)","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","Photo of proposer (passport size)","Photo of insured persons (stamp size)","Photo copy of cancelled cheque leaf"],"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 premium and acceptance of the 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 claim settlement.","The proposer consents to sharing information with government and regulatory authorities and service providers.","Concealment or misrepresentation will void the policy and claims will not be payable.","The company reserves the right to not renew the policy in case of fraud or non-disclosure.","The proposer consents to electronic communication and confirms payment source is legal.","The proposer agrees to professional conduct in communications with the company."],"dropped_labels":15},"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/5002-pa-common-proposal-form"}