{"id":604,"title":"INDUSIND - GROUP MEDICLAIM SUPER TOP UP INSURANCE (PLAN A) MASTER POLICY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-group-mediclaim-super-top-up-plan-a-master","sha256":"4a25e06dcb7355ea5d52b3a568ccdf42ba37bf6c3b7bb2b182e3a45a1acb9108","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the group master policyholder to apply for the IndusInd Group Mediclaim Super Top Up Insurance Plan A. The proposer (master policyholder) fills this form.","notes":["Use capital letters for name fields.","PAN number is mandatory; if not provided, Form 60 must be attached.","All payments to insured persons will be made only through electronic mode to the bank account provided.","Refer to the sales brochure, prospectus and policy wordings for full details on benefits, coverage, terms and exclusions.","Agent/intermediary must explain the form contents to the proposer and confirm understanding.","Prohibition of rebates as per Section 41 of the Insurance Act, 1938 applies.","Declarations and signatures must be provided by proposer and agent/intermediary as applicable."],"title":"INDUSIND - GROUP MEDICLAIM SUPER TOP UP INSURANCE (PLAN A) MASTER POLICY PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer’s Details (Master Policy Holder)","fields":[{"help":"Enter full name in capital letters; select appropriate title","type":"text","label":"Name of Proposer* (IN CAPITAL LETTERS)","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"","type":"text","label":"CIN Number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"GSTIN.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Entity Details:","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternative mobile number","type":"phone","label":"Alternative Mobile No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternative email address","type":"email","label":"Alternative Email:","options":[],"required":false,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address:","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter communication address","type":"text","label":"Communication Address:","options":[],"required":false,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Describe the business activity","type":"text","label":"Business of Proposer:","options":[],"required":false,"pdf_field":""},{"help":"Enter annual turnover amount","type":"amount","label":"Annual Turnover","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth: (Mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number or attach Form 60","type":"text","label":"PAN No.: (Mandatory) If not provided Form 60 required.","options":[],"required":true,"pdf_field":""},{"help":"Enter CKYC number if applicable","type":"text","label":"CKYC No.: (for Individual customer)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer (master policyholder)"},{"title":"Proposer's Bank Details","fields":[{"help":"Enter full name of bank account holder","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.:","options":[],"required":false,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account:","options":["Saving","Current"],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank:","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter 9 digit MICR code from cheque","type":"text","label":"MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)","options":[],"required":false,"pdf_field":""},{"help":"Enter 11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":false,"pdf_field":""},{"help":"Tick to confirm understanding","type":"checkbox","label":"I understand that any refund due on the premium payment I any payment I claims to be directly credited to my aforesaid Bank Account.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer (master policyholder)"},{"title":"Policy Coverage Options","fields":[{"help":"Select annual deductible amount in lakhs","type":"choice","label":"Annual Deductible Lacs (in INR)","options":["1 Lac","1.5 Lacs","2 Lacs","2.5 Lacs","3 Lacs","3.5 Lacs","5 Lacs","6 Lacs","7 Lacs","7.5 Lacs","8 Lacs","8.5 Lacs","9 Lacs","10 Lacs","12 Lacs","12.5 Lacs","15 Lacs","17 Lacs","17.5 Lacs","20 Lacs","22 Lacs","22.5 Lacs","25 Lacs","27 Lacs","30 Lacs","35 Lacs","40 Lacs","42.5 Lacs","45 Lacs","47 Lacs","47.5 Lacs","55 Lacs","60 Lacs","70 Lacs","80 Lacs","85 Lacs","90 Lacs","92.5 Lacs","95 Lacs","120 Lacs","130 Lacs"],"required":false,"pdf_field":""},{"help":"Select sum insured amount in lakhs","type":"choice","label":"Sum Insured Lacs (in INR)","options":["1 Lac","1.5 Lacs","2 Lacs","2.5 Lacs","3 Lacs","3.5 Lacs","5 Lacs","6 Lacs","7 Lacs","7.5 Lacs","8 Lacs","8.5 Lacs","9 Lacs","10 Lacs","12 Lacs","12.5 Lacs","15 Lacs","17 Lacs","17.5 Lacs","20 Lacs","22 Lacs","22.5 Lacs","25 Lacs","27 Lacs","30 Lacs","35 Lacs","40 Lacs","42.5 Lacs","45 Lacs","47 Lacs","47.5 Lacs","55 Lacs","60 Lacs","70 Lacs","80 Lacs","85 Lacs","90 Lacs","92.5 Lacs","95 Lacs","120 Lacs","130 Lacs"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"PEP Declaration","fields":[{"help":"Select yes or no","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide position if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please mention the name and relation and the position held by such close relative/family member.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter intermediary name in block letters","type":"text","label":"Intermediary Name","options":[],"required":false,"pdf_field":""},{"help":"Enter intermediary code","type":"text","label":"Code","options":[],"required":false,"pdf_field":""},{"help":"Enter IMD employee code","type":"text","label":"IMD Employee Code","options":[],"required":false,"pdf_field":""},{"help":"Enter IMD branch name","type":"text","label":"IMD Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Enter branch code","type":"text","label":"Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent/intermediary"}],"deadlines":[],"applies_to":"Group Master Policy for IndusInd Group Mediclaim Super Top Up Insurance (Plan A)","attachments":["Form 60 if PAN No. is not provided","Sales brochure, prospectus and policy wordings (for reference)"],"declarations":["I understand that all payments to the insured are only through electronic mode.","I understand that the information provided will form the basis of the insurance policy and the policy will come into force only after full payment of premium.","I will notify any change in occupation or health after proposal submission but before risk acceptance.","I consent to the company seeking medical and insurance information for underwriting and claim settlement.","I authorize the company to share my proposal information with government and regulatory authorities.","I confirm that premiums are paid from bonafide sources and not from proceeds of crime.","I understand the company can cancel the contract if found guilty under money laundering laws.","I declare that the information provided is true and complete to the best of my knowledge.","I will inform the company if I or my close relatives become Politically Exposed Persons (PEP) in future.","I have read and understood the product features, terms, conditions and exclusions."],"dropped_labels":2},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"+91 22 48903009","label":"Customer Care Paid Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"whatsapp","value":"+91 7400422200","label":"WhatsApp Support","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/about-us/grievance-redressal","quote":"ndinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:\nIndusInd General Insurance, 6th Floor, Commerz I, Oberoi Gard","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"services@indusindinsurance.com","label":"services email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/about-us/grievance-redressal","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91 22 48903009","label":"Paid Number","level":1,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/about-us/grievance-redressal","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"grievances@indusindinsurance.com","label":"Nodal Officer Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/about-us/grievance-redressal","quote":"m\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"headgrievances@indusindinsurance.com","label":"Head Grievances Email","level":3,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/about-us/grievance-redressal","quote":"s@indusindinsurance.com.\nStep 3\nIf the issue remains unresolved after Step 2, please escalate to:\n​Head Grievances\n​at ​headgrievances@indusindinsurance.com.​\nStep 4\nIf your concern remains unresolved after completing Steps 1, 2, and 3, you may approach the\nInsurance Ombudsma","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"022 4890 3009","label":"Grievance Redressal Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindinsurance.com/downloads/commercial-care-package-policy-pw-retail","quote":"hall not be liable to pay or contribute more than its rateable proportion of such loss or damage.\nindusindinsurance.com 022 4890 3009 (Paid) 74004 22200 (WhatsApp) IRDAI Registration No. 103 IndusInd General Insurance Company Limited (Formerly known as","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/indusind-general-insurance/604-indusind-group-mediclaim-super-top-up-insurance-plan-a-master-policy-proposal-fo"}