{"id":888,"title":"PROPOSAL FORM     National Young India Mediclaim Plus Policy","purpose":"proposal","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NYIMPP-Proposal_0.pdf","sha256":"c5875af6cab91ef733bdaef326c47e8c29b23e1360a9850a92210255a4802e64","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for a new or renewal health insurance policy under the National Young India Mediclaim Plus Policy. The proposer fills it with personal, nominee, insured persons, and policy details.","notes":["All fields are mandatory; do not leave any field blank or put dashes.","Details of proposer and up to 5 insured persons can be filled; attach additional forms if needed.","One stamp size photograph of each insured person must be affixed.","Use separate form for additional nominees.","Basic Sum Insured options are INR 5, 10, 15, 25 L per individual or floater.","Optional waiver of PED for Diabetes and/or Hypertension is available.","Attach required documents as per Annexure B.","Use block letters for names where specified.","Portability form is provided in Annexure A for transferring existing policies.","Original bills are not mentioned; photocopies of policies and documents are required.","Section 41 of Insurance Act prohibits rebates except as allowed."],"title":"PROPOSAL FORM     National Young India Mediclaim Plus Policy","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer / Insured Details","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/Business/Service/Other:","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number if available","type":"text","label":"PAN No:","options":[],"required":false,"pdf_field":""},{"help":"12-digit Aadhaar number","type":"text","label":"Aadhaar No:","options":[],"required":false,"pdf_field":""},{"help":"Ayushman Bharat Health Account number if available","type":"text","label":"ABHA No:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address / Contact Details","fields":[{"help":"10-digit mobile number","type":"phone","label":"Mobile No:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Full present address with district, state, and pin code","type":"text","label":"Present Address:","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address with district, state, and pin code","type":"text","label":"Permanent Address:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"","type":"text","label":"Name of Nominee:","options":[],"required":true,"pdf_field":""},{"help":"dd/mm/yyyy format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"PAN no:","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Fill only if nominee is a minor","type":"text","label":"Name of Guardian (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Percentage share for nominee","type":"number","label":"Percentage of claim amount payable:","options":[],"required":true,"pdf_field":""},{"help":"Nominee's present address with district, state, and pin code","type":"text","label":"Present Address:","options":[],"required":true,"pdf_field":""},{"help":"Nominee's permanent address with district, state, and pin code","type":"text","label":"Permanent Address:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"","type":"choice","label":"Is TPA service required?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Zone for premium?","options":["Zone I – Delhi, National Capital Region (NCR), Mumbai, Mumbai Suburban, Thane and Navi Mumbai, Gujarat, Hyderabad, Chennai, Indore","Zone II – Rest of India"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Type of Policy:","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Premium payment frequency:","options":["Annual","Half Yearly","Quarterly"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Do you require the physical set of insurance copy.","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Name as per bank records","type":"text","label":"Name in Bank Account:","options":[],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Bank:","options":[],"required":true,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch:","options":[],"required":true,"pdf_field":""},{"help":"Savings bank account number","type":"text","label":"SB Account No:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"IFSC:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Number in figures and words","type":"number","label":"No. of persons covered (including proposer)","options":[],"required":true,"pdf_field":""},{"help":"One stamp size photo per insured person","type":"photo","label":"Paste one stamp sized photographs and sign below","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Customer Code","options":[],"required":false,"pdf_field":""},{"help":"Full name of each insured person","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Date of birth in mm/dd/yyyy format","type":"date","label":"Date of Birth (mm/dd/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (M/F/TG)","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (cm)","options":[],"required":true,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight (kg)","options":[],"required":true,"pdf_field":""},{"help":"Blood group of the insured person","type":"text","label":"Blood Group","options":[],"required":true,"pdf_field":""},{"help":"Marital status","type":"text","label":"Marital Status","options":[],"required":true,"pdf_field":""},{"help":"Relationship to proposer","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Is the insured person dependent on proposer?","type":"yes-no","label":"Dependent (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Occupation of insured person","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Smoking habit","type":"yes-no","label":"Do you smoke? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Alcohol consumption habit","type":"yes-no","label":"Do you drink alcohol? (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Choose sum insured per individual or floater","type":"amount","label":"Basic Sum Insured #","options":["INR 5 L","INR 10 L","INR 15 L","INR 25 L"],"required":true,"pdf_field":""},{"help":"Optional waiver of PED for Hypertension","type":"checkbox","label":"Optional – Hypertension *","options":["Yes"],"required":false,"pdf_field":""},{"help":"Optional waiver of PED for Diabetes","type":"checkbox","label":"Optional – Diabetes *","options":["Yes"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Particulars","fields":[{"help":"","type":"yes-no","label":"Is there another Policy covering any/ all of the insured persons for hospitalisation?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Fill policy number, insurer, floater/individual, members covered with SI and CB, policy name, expiry date, last claimed date, claimed amount, porting (Y/N)","type":"table","label":"If yes, please give details below and attach policy copies","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"","type":"choice","label":"Premium Paid by:","options":["Cash","Cheque","DD","Others, specify"],"required":true,"pdf_field":""},{"help":"Premium amount paid","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Bank name if payment by cheque or DD","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Certificate from Proposer","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature of proposer or representative","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or representative"},{"title":"Portability Form (Annexure A)","fields":[{"help":"Existing policy number if porting","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Insured Person","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth/Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the policyholder/insured","options":[],"required":true,"pdf_field":""},{"help":"Fill name of insurance company, product, sum insured, cumulative bonus, add-ons/riders, policy number","type":"text","label":"Details of existing insurer","options":[],"required":true,"pdf_field":""},{"help":"Fill name of product proposed, sum insured proposed, whether cumulative bonus to be converted","type":"text","label":"Details of the proposed insurance","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Reason(s) for Portability","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"No. of family members to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Attach photocopies","type":"attachment","label":"Photocopy of the existing & previous policy documents","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy? (Please indicate Yes / NO):","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Agree to observe additional waiting period for specified diseases/treatments","type":"text","label":"If yes, please give written consent to the declaration below","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"National Young India Mediclaim Plus Policy","attachments":["One stamp size photograph of each insured person","Cancelled cheque (supporting bank account details)","Pre policy check up reports (if applicable)","Copy of existing health insurance policies (if applicable)","Proof of identity (any one document listed in Annexure B)","Proof of residence (any one document listed in Annexure B)","Copy of IT Certificate/ IT Return (wherever applicable)","Pan Details (in case PAN not available, Form 60 or 61 as per Rule 114B of the Income-tax Rule,1962 must be submitted)","Photocopy of the existing & previous policy documents (for portability)"],"declarations":["The statements made in the proposal form are true and complete to the best of the proposer's knowledge.","The information provided forms the basis of the insurance policy and the policy is effective only after premium payment and acceptance.","The proposer will notify any change in occupation or health after submission but before acceptance.","Consent is given to the insurer to seek medical and insurance information for underwriting and claim settlement.","Consent is given to share proposal and medical information with government and regulatory authorities.","The proposal form may be filled by a representative but the proposer accepts the coverage subject to terms and conditions.","No person shall offer or accept any rebate on premium or commission except as allowed by the insurer's prospectus or tables."],"dropped_labels":2},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customer.support@nic.co.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh Contrast\nInvert\nSaturation","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"18003450330","label":"Toll-Free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"033-22022100","label":"Head Office Telephone","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"d and Head Office\nPremises No. 18-0374, Plot No. CBD-81,\nNew Town, Kolkata-700156\nCIN: U10200WB1906GOI001713\nTelephone: 033-22022100\nFacebook\ninstagram\nX (Twitter)\nyoutube\nlinkedin\nWhatsapp\nBEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS /FRAUDULENT OFFE","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"9920501906","label":"WhatsApp Us","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/contact-us","quote":"h Us For Answers And Assistance—Your Gateway To Communication With Our Team.\nCustomer Service\n1800 345 0330\nWhatsApp Us\n9920501906\nHead Office\nPremises No. 18-0374, Plot No. CBD-81, New Town,  Kolkata - 700156\nTelephone: 033-22022100\nNote: Official c","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156","label":"Grievance Redressal Postal Address","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"e: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156 Insurance Ombudsman – As per Appendix attached to Policy. | 7\n12. | Things to Remember | Implied renewability (except o","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customer.relations@nic.co.in","label":"Grievance Redressal Officer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot no. CBD-81, New Town, Kolkata – 70015","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 345 0330","label":"Grievance Toll free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"holders Protection | • Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://nationalinsurance.nic.co.in/en/grievance","label":"Grievance Website","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"ice\n11. | Grievances/ Complaints | In case of any grievance the insured person may contact the company through Website: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No","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/national-insurance/888-proposal-form-national-young-india-mediclaim-plus-policy"}