{"id":636,"title":"INDUSIND - GROUP MEDICLAIM SUPER TOP UP INSURANCE - PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/group-mediclaim-super-top-up-proposal-form","sha256":"4f31e96110c9e76f57cdaa69bcc9cdecd5938c4da240bdd1503ea5b6bb9030a2","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the proposer (policyholder) to apply for the Group Mediclaim Super Top-up Insurance policy with IndusInd General Insurance Company Limited.","notes":["Fill all details in BLOCK LETTERS.","Attach expiring policy copy if applicable.","Attach separate list of persons proposed for insurance in specified format.","Policy copy and related documents will be sent to the email ID provided; request physical copy by email if needed.","Politically Exposed Persons (PEPs) must declare their status as per AML guidelines.","All payments to insured are made only through electronic mode as per IRDAI.","Use correct date format DD/MM/YYYY.","Prohibition of rebates as per Section 41 of Insurance Act, 1938 applies."],"title":"INDUSIND - GROUP MEDICLAIM SUPER TOP UP INSURANCE - PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Code","options":[],"required":null,"pdf_field":""},{"help":"","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 Details","fields":[{"help":"Fill in full name in block letters with title prefix","type":"text","label":"Name of Proposer","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"If available","type":"text","label":"Customer ID","options":[],"required":null,"pdf_field":""},{"help":"Include Flat/Building, Road/Street/Sector, Area, Taluka/Village/District/City, Pin Code, State, Country","type":"text","label":"Address for Communication","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Mobile number is mandatory","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhaar number if available","type":"text","label":"UID Aadhaar No.","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No.:","options":[],"required":false,"pdf_field":""},{"help":"","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":true,"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":true,"pdf_field":""},{"help":"Full name with title prefix","type":"text","label":"Name of Contact Person","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Contact person's phone number","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Contact person's email","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Describe the business activity","type":"text","label":"Business of the Proposer","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Whether all eligible employees/members of group/association/institution/Corporate Body are proposed for insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is this insurance is taken first time?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Number of years renewed if not first time","type":"number","label":"If no, Please mention no of renewal year","options":[],"required":false,"pdf_field":""},{"help":"Specify limits for each optional cover below","type":"text","label":"What are the optional covers / benefits required (please specify the limits required)","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Waiver of Waiting Period for Pre-Existing Disease","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for waiver of waiting period for pre-existing disease","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Waiver of Waiting Period for Specified Disease/procedure","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for waiver of waiting period for specified disease/procedure","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Waiver of 30 days waiting period","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for waiver of 30 days waiting period","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Basis of SI Coverage Required","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for basis of SI coverage","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Total number of main members plus dependents","type":"number","label":"No of lives to be covered under Floater","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Room Rent Limit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for room rent","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Waiver of Waiting Period for Maternity Cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for waiver of waiting period for maternity cover","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"Select if required and specify limits","type":"choice","label":"Change in Pre and Post Hospitalisation Limits","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Limits for change in pre and post hospitalisation","type":"text","label":"Specify the limits","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Policy period Start Date","options":[],"required":true,"pdf_field":""},{"help":"Columns: Sr. No., Name of Primary Insured Person/Names of family members, Cadre/Grade/Sub-Group, Emp Code / ID No. (for main members), Location, Date of Birth, Date of Joining of main member, Age, Relationship with the main member, Gender, Annual Deductible, Optional Cover, Sum Insured","type":"table","label":"Details of persons proposed for insurance (Please attach a separate list in the following format)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"The terms proposed are same as per your existing policy?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach expiring policy copy 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":"Columns: Year (1st, 2nd, 3rd), 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","type":"table","label":"Details of previous / expiring insurance policy for last 3 years?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"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":""},{"help":"Bank name on cheque/DD","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Cheque or DD Date","options":[],"required":true,"pdf_field":""},{"help":"Cheque or DD number","type":"text","label":"Cheque/DD No.","options":[],"required":true,"pdf_field":""},{"help":"PAN number of proposer","type":"text","label":"PAN No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer's Bank Details","fields":[{"help":"Full name with title prefix","type":"text","label":"Name of the Bank Account Holder","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"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":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"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":"11 character IFSC code","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":false,"pdf_field":""},{"help":"Mandatory as per IRDAI for electronic payments","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":"PEP Declaration","fields":[{"help":"","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":"","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 Undertakings","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign or thumb impression here","type":"signature","label":"Signature/Thumb impression of (Proposer)","options":[],"required":true,"pdf_field":""},{"help":"Full name with title prefix","type":"text","label":"Explained By Intermediary (Name)","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Date of explanation DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of explanation","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Intermediary","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Group Mediclaim Super Top Up Insurance","attachments":["Expiring policy copy if terms are same","Separate list of persons proposed for insurance in specified format"],"declarations":["All premiums paid are from bonafide sources and not from proceeds of crime.","Company may call for documents to establish source of funds.","Company may cancel contract if found guilty under money laundering laws.","Proposer consents to KYC and PAN verification and accepts responsibility for mismatches.","Information provided forms basis of insurance and policy is subject to underwriting and full premium receipt.","Proposer will notify any change in occupation or health before risk acceptance.","Company may seek medical and insurance information for underwriting and claims.","Company may share proposal information with government or regulatory authorities.","Receipt of proposal does not mean acceptance; coverage starts after premium receipt and underwriting.","Policy may be voided for misrepresentation or non-disclosure.","Insured persons will undergo medical exams or tests as required.","Proposer consents to provide valid age and identity proof when required.","Proposer consents to receive information via physical, electronic or telecommunication means.","Proposer declares all information is true and complete and is authorized to propose for others.","Address given will be used for GST purposes.","Proposer confirms understanding of proposal contents and contract significance.","Refunds and payments will be credited only to the proposer’s bank account as per IRDAI guidelines."],"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/636-indusind-group-mediclaim-super-top-up-insurance-proposal-form"}