{"id":889,"title":"PROPOSAL FORM National Parivar 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/NPMPP%20Proposal%20Form.pdf","sha256":"bbc89300c8f5bcca4558727f55811c74abd88ccddaf53ebbb5276b8843e310b8","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is for individuals proposing to purchase or renew the National Parivar Mediclaim Plus health insurance policy. The proposer fills it with details about themselves, insured persons, and policy preferences.","notes":["Do not leave any space blank or put dashes; fill all mandatory fields.","Attach two stamp size photographs per insured person; one to be affixed on the form.","Persons aged 60 or above or opting for Critical Illness must submit pre-policy checkup reports up to 1 month old and complete Annexure A.","For additional members beyond 8 insured persons, use a fresh proposal form.","Use block letters where indicated.","Original documents may be required for verification.","Refer to Annexure C for acceptable identity and residence proofs.","Policy acceptance is subject to company approval and full premium payment."],"title":"PROPOSAL FORM National Parivar Mediclaim Plus Policy","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposal Details","fields":[{"help":"Select whether this is a new policy or a renewal with changes","type":"choice","label":"Proposal for New Policy Renewal (with change in details)","options":["New Policy","Renewal (with change in details)"],"required":true,"pdf_field":""},{"help":"Enter start and end dates of the policy period","type":"date","label":"Policy Period: From To midnight of","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Details","fields":[{"help":"Select appropriate title","type":"choice","label":"Mr. Ms. Mrs.","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Full name of the proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Specify occupation or business","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":"Aadhaar number if available","type":"text","label":"Aadhaar No","options":[],"required":false,"pdf_field":""},{"help":"ABHA number if available","type":"text","label":"ABHA No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address / Contact Details","fields":[{"help":"Mobile phone number","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Full present address including district, state, and pin code","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address including district, state, and pin code","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of nominee","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"PAN number of nominee if available","type":"text","label":"PAN no","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of nominee","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Email ID of nominee","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Guardian name if nominee is minor","type":"text","label":"Name of Guardian (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of claim amount payable to nominee","type":"number","label":"Percentage of claim amount payable","options":[],"required":true,"pdf_field":""},{"help":"Nominee's present address including district, state, and pin code","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Nominee's permanent address including district, state, and pin code","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Select if Third Party Administrator service is required","type":"yes-no","label":"Is TPA service required?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select premium paying zone","type":"choice","label":"Premium paying Zone","options":["Zone I","Zone II","Zone III","Zone IV"],"required":true,"pdf_field":""},{"help":"Select policy duration","type":"choice","label":"Policy duration","options":["1 year","2 years","3 years"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Name as per bank account","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":"Bank IFSC code","type":"text","label":"IFSC","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Number of insured persons including proposer","type":"number","label":"No. of persons covered (including proposer)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Select outpatient treatment cover limit per family","type":"choice","label":"Outpatient Treatment (Write Limit of Cover required)","options":["INR 2,000","3,000","4,000","5,000","10,000","15,000","20,000","25,000"],"required":false,"pdf_field":""},{"help":"Select critical illness benefit amount per individual; must not exceed sum insured","type":"choice","label":"Critical Illness (Write Benefit Amount required per individual)","options":["INR 2,00,000","3,00,000","5,00,000","10,00,000","15,00,000","20,00,000","25,00,000"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of premium payment","type":"choice","label":"Premium Paid by: Cash Cheque DD Others, specify","options":["Cash","Cheque","DD","Others"],"required":true,"pdf_field":""},{"help":"Enter 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":"Sign to declare all information is true and consent to terms","type":"signature","label":"Signature of the proposer","options":[],"required":true,"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":""}],"filled_by":"proposer"},{"title":"Certificate from Proposer","fields":[{"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":""},{"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":""}],"filled_by":"proposer or representative"},{"title":"Annexure A: Medical Examination Report","fields":[{"help":"Name of insured person examined","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Describe current complaints and investigations","type":"text","label":"Present complaints and investigation, if any","options":[],"required":false,"pdf_field":""},{"help":"Provide past medical history details","type":"text","label":"Any past history of disease, operations, accidents, investigations with date, major medical complaints of hospitalisation?","options":[],"required":false,"pdf_field":""},{"help":"List medications and duration","type":"text","label":"Details of present and past medication with duration","options":[],"required":false,"pdf_field":""},{"help":"State cure status and treatment dates","type":"text","label":"Is he cured of diseases, if any? When was your treatment, if any, given, stopped?","options":[],"required":false,"pdf_field":""},{"help":"General examination findings","type":"text","label":"General examination","options":[],"required":false,"pdf_field":""},{"help":"Systematic examination findings","type":"text","label":"Systematic examination","options":[],"required":false,"pdf_field":""},{"help":"Name and qualification of medical examiner","type":"text","label":"Name of Medical Examiner & qualification","options":[],"required":true,"pdf_field":""},{"help":"Registration number of medical examiner","type":"text","label":"Regd. No","options":[],"required":true,"pdf_field":""},{"help":"Address of medical examiner","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Medical examiner's signature","type":"signature","label":"Signature of Medical Examiner","options":[],"required":true,"pdf_field":""},{"help":"Date of medical examination","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Proposer's signature confirming report","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"consulting physician/surgeon"},{"title":"Annexure B: Portability Form","fields":[{"help":"Name of policyholder or insured","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Date of birth or age","type":"date","label":"Date of Birth/Age","options":[],"required":true,"pdf_field":""},{"help":"Full address","type":"text","label":"Address of the policyholder/insured","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for portability","type":"text","label":"Reason(s) for Portability","options":[],"required":true,"pdf_field":""},{"help":"Number of family members to port","type":"number","label":"No. of family members to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Attach photocopies of existing and previous policies","type":"attachment","label":"Photocopy of the existing & previous policy documents","options":[],"required":true,"pdf_field":""},{"help":"Indicate if waiting periods are longer","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy? (Yes/No)","options":["Yes","No"],"required":true,"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":"Signature confirming portability form","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"National Parivar Mediclaim Plus Policy","attachments":["Two stamp size photographs of each insured person","Pre policy checkup reports (if applicable)","Copy of existing health insurance policies (if applicable)","Cancelled cheque (supporting bank account details)","Proof of identity (any one document listed in Annexure C)","Proof of residence (any one document listed in Annexure C)","Copy of IT Certificate/ IT Return (wherever applicable)","PAN Details or Form 60 or 61 as per Rule 114B of the Income-tax Rule,1962"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will come into force only after receipt of the premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The company is authorized to seek medical and insurance information for underwriting and claims.","The company may share proposal and medical information with government or regulatory authorities.","Incorrect information may void the policy and forfeit premiums paid."],"dropped_labels":10},"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/889-proposal-form-national-parivar-mediclaim-plus-policy"}