{"id":5005,"title":"Proposal Form for Package Products - Unique Reference No.: SHAI/PR0007","purpose":"proposal","insurer":{"slug":"star-health-and-allied-insurance","name":"Star Health & Allied Insurance Co.Ltd."},"source_pdf":"https://d28c6jni2fmamz.cloudfront.net/Proposal_Form_FHOAC_and_MCIAC_Insurance_Policy_V_4_Web_18ded6d606.pdf","sha256":"9d1f8bea7aaaf444c0cdb7dd26c8d94889eed4b060660c36241305ac5c5447fd","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals (proposers) to apply for the Medi Classic Accident Care (Individual) Insurance Policy and related package products offered by Star Health and Allied Insurance Company Limited.","notes":["Fill the form in block letters.","Attach original or valid proofs as specified.","Cash payments are not eligible for 80D tax benefits.","Patient Care add-on is available only for insured persons above 60 years of age.","If nominee is minor, provide name of appointee.","Attach separate sheet if additional space is needed for health details.","Beware of fraudulent calls and do not share sensitive information like OTP or passwords.","The copy of PAN card or Form 60 is mandatory unless CKYC number is provided.","Use the policy term and period of insurance as per your choice.","Multiple policies exceeding maximum sum insured may be cancelled by the company."],"title":"Proposal Form for Package Products - Unique Reference No.: SHAI/PR0007","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Declarations","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 as defined in the form","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 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":"Fill 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 government ID and address proof","type":"choice","label":"Please attach any one proof in support of ID and Address","options":["Voter ID","Driving License (with Exp Dt.)","Aadhar Card","Passport (with Exp Dt.)","NREGA Job Card","Any Other Govt. Notified Document"],"required":true,"pdf_field":""},{"help":"Fill nominee name","type":"text","label":"Nominee’s Name","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to nominee","type":"text","label":"Relationship to Nominee","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship to Proposer","options":[],"required":true,"pdf_field":""},{"help":"Choose if you want a physical copy of the policy","type":"choice","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 you do not have an 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":"","type":"yes-no","label":"Do you wish to update CKYC with the KYC details provided here","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select your business type and provide annual income if applicable","type":"choice","label":"Business Type","options":["Salaried","Business","Annual Income (in Rs.)"],"required":false,"pdf_field":""},{"help":"Social Sector includes unorganised, informal, economically vulnerable or backward classes","type":"yes-no","label":"Do you come under below mentioned Social Sector Classification*","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Tick applicable social sector classification","type":"checkbox","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":"Provide 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":"","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":"Fill father's or spouse's name","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"Fill mother's name","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":"Specify source of income","type":"text","label":"Source of Income","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN or Form 60 as applicable","type":"text","label":"IT Returns / 3mths Payslip / PAN Number / If PAN number is not available submit Form 60","options":[],"required":true,"pdf_field":""},{"help":"Select residential status","type":"choice","label":"Residential Status","options":["Indian Resident","NRI","PIO","Foreign National"],"required":true,"pdf_field":""},{"help":"Provide email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Specify any other proof submitted","type":"text","label":"Other Proof, please specify","options":[],"required":false,"pdf_field":""},{"help":"Specify proof of income submitted","type":"text","label":"Proof of Income to be submitted","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":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of the Proposer and Payment Details","fields":[{"help":"Select bank account type","type":"choice","label":"Type of Account","options":["Current Account","Savings Account"],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank 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":"Date of payment in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount Rs.","options":[],"required":true,"pdf_field":""},{"help":"Bank branch for payment","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque or demand draft number if applicable","type":"text","label":"Cheque / DD No.","options":[],"required":false,"pdf_field":""},{"help":"Attach cancelled cheque copy","type":"attachment","label":"Please attach a photo copy of cancelled cheque leaf","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment (Cash payments are not eligible for 80D tax benefits)","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Debit Card","Credit Card","NEFT","ECS","Cash"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Person(s) Proposed for Insurance","fields":[{"help":"Enter full name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender for each insured person","type":"choice","label":"Gender","options":["M","F","Transgender"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format for each insured person","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":"Specify occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Enter monthly income if applicable","type":"amount","label":"What is the monthly income from Gainful Employment (in Rs.)","options":[],"required":false,"pdf_field":""},{"help":"Provide ABHA number if available","type":"text","label":"Ayushman Bharat Health Account (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no for Gold Plan","type":"yes-no","label":"Do you want Gold Plan in Section I [Applicable for Medi Classic Accident Care (Individual) Insurance Policy]","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured Opted (Rs.) in Section I [Applicable for Medi Classic Accident Care (Individual) Insurance Policy]","options":[],"required":true,"pdf_field":""},{"help":"Tick add-ons if desired (Patient Care add-on only for insured persons above 60 years)","type":"checkbox","label":"Do you want Add-ons in Section I [Applicable for Medi Classic Accident Care (Individual) Insurance Policy]","options":["Hospital Cash","Patient Care"],"required":false,"pdf_field":""},{"help":"Enter sum insured for Section II if applicable","type":"amount","label":"Sum Insured (Rs.) Opted in Section II","options":[],"required":false,"pdf_field":""},{"help":"Select risk group based on occupation","type":"choice","label":"Risk Group* (RG)","options":["RG - I","RG - II","RG - III"],"required":true,"pdf_field":""},{"help":"Provide details of existing insurance policies","type":"text","label":"Existing Insurance Coverage with us and/or any other company give details","options":[],"required":false,"pdf_field":""},{"help":"Provide ailment, year, and claim amount paid/rejected for each claim","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":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer all health questions 1 to 11; attach separate sheet if needed","type":"text","label":"Health History: Please provide detailed, response-specific diagnosis and treatment","options":[],"required":true,"pdf_field":""},{"help":"Provide family physician's name","type":"text","label":"Family Physician's Name","options":[],"required":false,"pdf_field":""},{"help":"Provide family physician's phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Provide family physician's registration number","type":"text","label":"Regn No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"Date of 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":[],"applies_to":"Medi Classic Accident Care (Individual) Insurance Policy and Family Health Optima Accident Care Policy","attachments":["One proof in support of ID and Address (e.g. Voter ID, Driving License, Aadhar Card, Passport, NREGA Job Card, Any Other Govt. Notified Document)","Photograph of the Proposer (passport size)","Photograph of each Insured Person (stamp size)","Photo copy of cancelled cheque leaf","Medical documents if applicable","Insurance Agent’s Confidential Report (if any)","Separate sheet for additional health details if needed"],"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 by the insurer.","The proposer will notify any change in occupation or health after submission but before acceptance.","The proposer consents to the insurer seeking medical and other information for underwriting and claims.","The proposer authorizes premium deduction from the given bank account and confirms source of funds is legal.","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 receiving communications and sharing of information as per company policies.","The proposer agrees to professional conduct and acknowledges consequences of unprofessional behavior."],"dropped_labels":9},"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/5005-proposal-form-for-package-products-unique-reference-no-shai-pr0007"}