{"id":5003,"title":"Saral Suraksha Bima, Star Health And Allied Insurance Co Ltd - Unique Reference No.: SHAI/PR0062","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Proposal_Form_Saral_Suraksha_Bima_V_8_Web_d216f668e6.pdf","sha256":"58ff3d0e3be79e00e3dc867cb8080a45cae1bd1ba906fc0a24e0e4cc044a2156","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is a proposal form for applying for the Saral Suraksha Bima health insurance policy from Star Health and Allied Insurance Co Ltd. It is filled by the proposer who wishes to purchase the insurance.","notes":["Fill the form in block letters.","Attach original or valid documents as proof where required.","Cash payments are not eligible for 80D tax benefits.","Use the annexure nomination form if multiple nominees are to be specified.","Beware of fraudulent calls or emails asking for personal or payment information.","The proposal form must be filled honestly and completely to avoid policy invalidation.","The proposer or insured persons must disclose all relevant health information.","The form includes sections for multiple insured persons up to five.","The proposer must sign or provide thumb impression; if illiterate, the form must be explained and signed by a witness."],"title":"Saral Suraksha Bima, Star Health And Allied Insurance Co Ltd - Unique Reference No.: SHAI/PR0062","submit":{"to":"Star Health and Allied Insurance Company Limited","how":"","address":"Registered Office: No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034"},"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":null,"pdf_field":""},{"help":"","type":"text","label":"Business Type","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you a ASHA worker","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Are you a MGNREGA worker","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick applicable category if Yes to 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":null,"pdf_field":""},{"help":"Enter proposer’s first name in block letters","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"Enter middle name if any","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Enter proposer’s last name in block letters","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":"Sign or put 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":""}],"filled_by":"proposer"},{"title":"Nomination Details","fields":[{"help":"Enter name of nominee","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee’s relationship to proposer","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee’s relationship to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee’s date of birth if minor","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee’s age in years","type":"number","label":"Age in yrs","options":[],"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":""}],"filled_by":"proposer"},{"title":"Contact and Address Details","fields":[{"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":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Attach one valid ID and address proof document","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","Other Govt. Notified Document"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy and Payment Details","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Do you want to pay the premium in Instalments","options":["Yes","No"],"required":true,"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 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 cheque or demand draft number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":false,"pdf_field":""},{"help":"Select type of bank account","type":"choice","label":"Type of Account","options":["Current Account","Savings Account","Others"],"required":false,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Attach cancelled cheque copy for bank details verification","type":"attachment","label":"Please attach a photo copy of cancelled cheque leaf","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount in lakhs for floater policy","type":"amount","label":"Sum Insured on Floater Basis in Lakhs** Rs.","options":[],"required":true,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy Type (Please )","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Person Proposed for Insurance","fields":[{"help":"Enter full name of insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","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":"Enter relationship to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter occupation or trade","type":"text","label":"Occupation/Trade/Business","options":[],"required":true,"pdf_field":""},{"help":"Enter ABHA number if available","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"Enter monthly income in rupees","type":"amount","label":"What is the monthly income from Gainful Employment (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured amount for base cover","type":"amount","label":"Sum Insured for Base Cover (Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization Cover due to Accident (Optional Cover)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Educational Grant (optional Cover)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"TTD (Optional Cover)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select applicable risk group","type":"choice","label":"Risk Group","options":["Risk Group I - Persons engaged primarily in administrative functions","Risk Group II - Persons engaged in manual work other than what is specifically provided for under Risk Group III","Risk Group III - Persons working in explosives industry, mine and/or Magazine workers, high tension electric supply, horse racing including jockeys, athletes and occupations of similar hazard"],"required":true,"pdf_field":""},{"help":"Provide details of any past or current illness or injury","type":"text","label":"2) Has the person proposed for insurance consulted / diagnosed / taken treatment / been admitted for any illness / injury. If yes, give details","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"1) Does the occupation of the proposed persons require engaging in manual labour","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"2) 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":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"3) Has/Is the proposed person suffered/ suffering from Physical defect or infirmity or any other disability. If yes give details.","options":[],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"4) Has the person ever proposed for any personal accident insurance. If yes details of Insurance Company Period of Insurance Sum Insured.","options":[],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"5) Has any company Declined to issue a policy or Imposed any restrictions / special conditions","options":[],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"6) Has the proposed person ever claimed or received compensation under any Accident Policy? If yes, give full details","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","Others"],"required":true,"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":[],"applies_to":"Saral Suraksha Bima health insurance policy","attachments":["Passport size photograph of the Proposer","Stamp size photograph of Insured Person - 1","Stamp size photograph of Insured Person - 2","Stamp size photograph of Insured Person - 3","Stamp size photograph of Insured Person - 4","Stamp size photograph of Insured Person - 5","Photo copy of cancelled cheque leaf","Proof of ID and Address (one of Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card, Other Govt. Notified Document)","PAN card or Form 60"],"declarations":["The proposer declares that all statements and particulars are 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 by the insurer.","The proposer will notify any change in occupation or health before risk acceptance.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes sharing of proposal and medical data with government and regulatory authorities.","The proposer confirms payment source is legal and no third-party payments are allowed.","The proposer agrees to receive communications from the insurer and consents to override NCPR.","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."],"dropped_labels":6},"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/5003-saral-suraksha-bima-star-health-and-allied-insurance-co-ltd-unique-reference-no-"}