{"id":634,"title":"GROUP MEDICLAIM - PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/proposal-form-for-group-mediclaim","sha256":"36473f2f509f4451351dff6e77f76dcd9e0ae3d5e0de2d8b5a37c750827bd193","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (usually an employer or group administrator) to apply for a Group Mediclaim insurance policy for eligible employees or members.","notes":["Fill all details in BLOCK LETTERS where specified.","Attach expiring policy copy if terms are same as existing policy.","Attach separate list of persons proposed for insurance in specified format.","All payments to insured will be made only through electronic mode as per IRDAI guidelines.","Politically Exposed Persons (PEPs) are defined as per RBI KYC guidelines.","Use original and accurate documents for KYC and identity verification.","Proposal form completion does not guarantee policy issuance; subject to underwriting and premium receipt."],"title":"GROUP MEDICLAIM - PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"Fill in BLOCK LETTERS","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"Fill in BLOCK LETTERS","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"Fill in BLOCK LETTERS","type":"text","label":"Sales Manager Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Code","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary"},{"title":"Proposer's Details","fields":[{"help":"Select title and write full name in BLOCK LETTERS","type":"text","label":"Proposer's Full Name","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Customer ID","options":[],"required":null,"pdf_field":""},{"help":"Fill complete address and contact details","type":"text","label":"Address for Communication Flat/Building/Door/Block No. Road/Street/Sector: Area Taluka/Village/District/ City Pinode State Country Phone Mobile Email Fax","options":[],"required":true,"pdf_field":""},{"help":"Enter Aadhaar number if available","type":"text","label":"UID Aadhaar No.","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.:","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Do you have a GST Registration Number","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide GST number if applicable","type":"text","label":"If Yes, please specify","options":[],"required":false,"pdf_field":""},{"help":"Select the source of funds","type":"choice","label":"Source of Funds","options":["Business","Profession","Salary","Agricultural Income","Savings","Others"],"required":null,"pdf_field":""},{"help":"Select monthly income range","type":"choice","label":"Monthly Income","options":["Upto ` 20,000","` 20,001 to ` 50,000","` 50,001 to ` 1,00,000","` 1,00,001 and above"],"required":null,"pdf_field":""},{"help":"Name of person to contact for this proposal","type":"text","label":"Name of Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Contact email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Describe the business activity","type":"text","label":"Business of the Proposer","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Whether all eligible employees/members of group/association/institution/Corporate Body are proposed for insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Is this insurance is taken first time?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter number of renewal years if applicable","type":"number","label":"If no, Please mention no of renewal year","options":[],"required":false,"pdf_field":""},{"help":"Specify any additional benefits and limits","type":"text","label":"What are the other extensions / benefits required (please specify the limits required)","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Coverage of Pre-existing diseases","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for pre-existing diseases coverage","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Benefits and Policy Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Waiver of first year exclusions","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for waiver of first year exclusions","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Waiver of 30 day waiting period","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for waiver of 30 day waiting period","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""},{"help":"Select basis of sum insured coverage","type":"choice","label":"Basis of SI Coverage Required","options":["Floater","Individual"],"required":null,"pdf_field":""},{"help":"Specify limits for sum insured coverage","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""},{"help":"Enter number of main members, dependents and total lives","type":"text","label":"No of lives to be covered under Floater No. of Main Members + No. of Dependent Total Lives","options":[],"required":null,"pdf_field":""},{"help":"Select all applicable relationships; specify others if any","type":"checkbox","label":"Relationships to be covered","options":["Self","Spouse","Dependent Children","Dependent Parents","Others"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Maternity Extension benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for normal delivery","type":"text","label":"In case of yes please specify limits required Normal","options":[],"required":false,"pdf_field":""},{"help":"Specify limits for C Section delivery","type":"text","label":"C Section","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Waiver of 9 months waiting period for Maternity benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for waiver of maternity waiting period","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Removal of Domiciliary Hospitalisation Benefit","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify limits for removal of domiciliary hospitalization benefit","type":"text","label":"Specify the Limits","options":[],"required":false,"pdf_field":""},{"help":"Attach a separate list with these columns filled","type":"table","label":"Details of persons proposed for insurance (Please attach a separate list in the following format) Sr. No Name of the main member/ Names of family members ID No. (for main members) Date of Birth Date of Joining of main member Relationship with the main member Gender Sum Insured Previous Insurance Details","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"The terms proposed are same as per your existing policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach copy of expiring policy and mention policy number","type":"text","label":"If yes please provide expiring policy copy along with this proposal form and provide policy no","options":[],"required":false,"pdf_field":""},{"help":"List additional coverages if terms differ","type":"text","label":"If no, please list out the additional coverages:","options":[],"required":false,"pdf_field":""},{"help":"Provide details for previous years if applicable","type":"text","label":"The terms proposed are same as per 1st Year 2nd Year 3rd Year No of lives covered at inception No. of lives at expiry Incurred Claims Paid + O/s (Count & Amount) Premium before service tax Name of the insurance company Name of the TPA","options":[],"required":false,"pdf_field":""},{"help":"Select mode of payment","type":"choice","label":"Payment Details","options":["Cheque","DD"],"required":true,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Cheque / DD Amount","options":[],"required":true,"pdf_field":""},{"help":"Write amount in words","type":"text","label":"Amount in words","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details of Proposer","fields":[{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque or DD date in DD/MM/YYYY format","type":"date","label":"Cheque or DD Date","options":[],"required":true,"pdf_field":""},{"help":"Enter cheque or DD number","type":"text","label":"Cheque/DD No.","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":true,"pdf_field":""},{"help":"Select title and enter full name","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account","options":["Saving","Current"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter 9 digit MICR code","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":true,"pdf_field":""},{"help":"Enter 11 character IFSC code","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Tick to confirm understanding of electronic payment","type":"checkbox","label":"I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by Proposer","fields":[{"help":"Sign and affix company seal","type":"signature","label":"Signature of Proposer & Company Seal","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":"Vernacular Declaration","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Name and signature of person identifying proposer","type":"text","label":"Identified by Name & Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of vernacular declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of vernacular declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date intermediary explained the form","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place intermediary explained the form","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Signature of intermediary","type":"signature","label":"Intermediary Signature","options":[],"required":true,"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":"Specify 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":"AML Guidelines Declaration","fields":[{"help":"Sign and affix company seal","type":"signature","label":"Signature of Proposer & Company Seal","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group Mediclaim policies","attachments":["Expiring policy copy if terms are same as existing policy","Separate list of persons proposed for insurance in specified format"],"declarations":["I have read and understood the brochure, prospectus, sales literature & policy wordings and agree to abide by them.","The information provided forms the basis of the insurance policy and the policy commences only after full premium receipt.","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 sharing of proposal and medical information with government and regulatory authorities.","Receipt of proposal does not mean acceptance; coverage starts only after premium receipt and underwriting.","Policy may be voided if any information is untrue, incorrect, or withheld.","Proposed insured persons will undergo medical exams or tests as required by the company.","I consent to provide valid age and identity proof when required.","I consent to receive information from the company by physical, electronic, or telecommunication means.","I declare that all statements are true and I am authorized to propose on behalf of all persons insured.","The address given will be used for GST purposes.","I confirm that the proposal contents have been fully explained and understood.","I confirm premiums are paid from bonafide sources and not from proceeds of crime.","The company may call for documents to verify source of funds.","The company may cancel the contract if found guilty under money laundering laws.","I will inform the company if I or close relatives become Politically Exposed Persons (PEP).","I understand that offering or accepting rebates on premiums or commission is prohibited by law."],"dropped_labels":3},"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/634-group-mediclaim-proposal-form"}