{"id":890,"title":"PROPOSAL FORM National 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/NMPP%20Proposal%20Form.pdf","sha256":"0a7bd09907b6743d8d9db410d2cf7464fb3ba78adc630007f275aa5c3bee2757","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for a new or renewal health insurance policy under the National Mediclaim Plus Policy. It is filled by the proposer who wishes to insure themselves and up to 7 other insured persons.","notes":["Do not leave any space blank or put dashes; fill all mandatory fields.","Details of up to 8 insured persons can be filled; use a fresh form for additional members.","Two stamp size photographs per insured person are required; one to be affixed on the form.","Persons aged 40 or above or opting for sum insured above ₹5 lacs or critical illness cover must submit pre-policy checkup reports up to 1 month old and complete Annexure A.","Portability form is provided in Annexure B.","Use original documents for proofs as listed in Annexure C.","Sum insured options vary by plan; critical illness benefit amount must not exceed sum insured.","Fill all tables completely; do not leave blanks.","Proposal form must be signed by proposer or their representative if proposer is a person with disability."],"title":"PROPOSAL FORM National Mediclaim Plus Policy","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Select your title","type":"choice","label":"Mr. Ms. Mrs.","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Enter full name of the proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Specify your occupation or business","type":"text","label":"Occupation/Business/Service/Other","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number if available","type":"text","label":"PAN No","options":[],"required":false,"pdf_field":""},{"help":"Enter Aadhaar number if available","type":"text","label":"Aadhaar No","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number if available","type":"text","label":"ABHA No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address / Contact Details","fields":[{"help":"Enter mobile phone number","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter current residential address","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Enter district of present address","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state of present address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code of present address","type":"number","label":"Pin","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent residential address","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""},{"help":"Enter district of permanent address","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state of permanent address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal PIN code of permanent address","type":"number","label":"Pin","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter full name of nominee","type":"text","label":"Name of Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth (dd/mm/yyyy)","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to proposer","type":"text","label":"Relationship with proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of nominee if available","type":"text","label":"PAN no","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number of nominee","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter email ID of nominee","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""},{"help":"Enter guardian's name if nominee is minor","type":"text","label":"Name of Guardian (if nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage share of claim amount payable to nominee","type":"number","label":"Percentage of claim amount payable","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's present address","type":"text","label":"Present Address","options":[],"required":true,"pdf_field":""},{"help":"Enter district of nominee's present address","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state of nominee's present address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter PIN code of nominee's present address","type":"number","label":"Pin","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's permanent address","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""},{"help":"Enter district of nominee's permanent address","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"Enter state of nominee's permanent address","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter PIN code of nominee's permanent address","type":"number","label":"Pin","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 plan option","type":"choice","label":"Plan option","options":["Plan A","Plan B","Plan C"],"required":true,"pdf_field":""},{"help":"Select co-payment option","type":"choice","label":"Is Co-payment opted?","options":["20%","10%","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Enter name as per bank account","type":"text","label":"Name in Bank Account","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter savings bank account number","type":"text","label":"SB Account No","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Enter number of persons covered in figures and words","type":"number","label":"No. of persons covered (including proposer)","options":[],"required":true,"pdf_field":""},{"help":"Enter customer code if available","type":"text","label":"Customer Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Particulars","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Is there an active Base Policy covering any/all of the insured persons for hospitalisation?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Select if opting for outpatient treatment cover","type":"choice","label":"Outpatient Treatment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select outpatient treatment cover limit per individual","type":"choice","label":"Limit of Cover required","options":["₹2,000","₹3,000","₹4,000","₹5,000","₹10,000"],"required":false,"pdf_field":""},{"help":"Select if opting for critical illness cover","type":"choice","label":"Critical Illness","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select critical illness benefit amount per individual; must not exceed sum insured","type":"choice","label":"Benefit Amount required per individual","options":["₹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","options":["Cash","Cheque","DD","Others"],"required":true,"pdf_field":""},{"help":"Enter premium amount paid","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"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":""}],"filled_by":"proposer"},{"title":"Certificate from Proposer","fields":[{"help":"Signature of proposer or representative","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","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":"Annexure A: Medical Examination Report - Personal History","fields":[{"help":"Enter name of insured person","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 with dates","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":"Provide general examination findings","type":"text","label":"General examination","options":[],"required":false,"pdf_field":""},{"help":"Provide systematic examination findings","type":"text","label":"Systematic examination","options":[],"required":false,"pdf_field":""},{"help":"Enter name and qualification of medical examiner","type":"text","label":"Name of Medical Examiner & qualification","options":[],"required":true,"pdf_field":""},{"help":"Enter registration number","type":"text","label":"Regd.No","options":[],"required":true,"pdf_field":""},{"help":"Enter address of medical examiner","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Medical examiner to sign","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 to sign","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"consulting physician/surgeon"},{"title":"Annexure B: Portability Form","fields":[{"help":"Enter name(s) of policyholder/insured","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth or age","type":"text","label":"Date of Birth/Age","options":[],"required":true,"pdf_field":""},{"help":"Enter address","type":"text","label":"Address of the policyholder/insured","options":[],"required":true,"pdf_field":""},{"help":"Provide details: Name of insurance company, product name, sum insured, cumulative bonus, add-ons/riders taken, policy number","type":"text","label":"Details of existing insurer","options":[],"required":true,"pdf_field":""},{"help":"Provide proposed product name, sum insured, whether cumulative bonus to be converted","type":"text","label":"Details of the proposed insurance","options":[],"required":true,"pdf_field":""},{"help":"Explain reasons for portability","type":"text","label":"Reason(s) for Portability","options":[],"required":true,"pdf_field":""},{"help":"Enter number of family members","type":"number","label":"No. of family members to be included in the policy to be ported","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":"insured"}],"deadlines":[],"applies_to":"National Mediclaim Plus Policy","attachments":["Two stamp size photographs of each insured person (one to be affixed on the Proposal form)","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 proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full receipt of the premium chargeable.","The proposer will notify in writing any change in occupation or health after submission but before risk acceptance.","The proposer consents to the insurer seeking medical and insurance information for underwriting and claim settlement.","The proposer authorizes sharing of proposal and medical information with government and regulatory authorities.","If any information is found incorrect during policy currency, the policy shall be void and premiums forfeited."],"dropped_labels":7},"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/890-proposal-form-national-mediclaim-plus-policy"}