{"id":892,"title":"New National Parivar Mediclaim Policy PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NNPMP%20Proposal%20Form.pdf","sha256":"2993140efd3c3b466b7a00ca710d7373f89dc189085193eb05c13275e8b41ca9","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for a new or renewal health insurance policy under the New National Parivar Mediclaim Policy. The proposer fills it to provide personal, nominee, insured persons, and policy details for underwriting.","notes":["All fields are mandatory; do not leave any blank or put dashes.","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 60 or above or opting for Critical Illness must submit pre-policy checkup reports up to 1 month old and complete Annexure A.","Portability form is provided in Annexure B.","Use block letters for names where specified.","Attach original or valid documents as per Annexure C.","Policy will not be on risk until acceptance and full premium payment."],"title":"New National Parivar Mediclaim Policy PROPOSAL FORM","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","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":"Name of guardian 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 copayment option if any","type":"choice","label":"Optional Copayment?","options":["No","15%","20%"],"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":""},{"help":"Select instalment payment option if required","type":"choice","label":"Instalment Facility","options":["No","Quarterly","Half Yearly"],"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":"Enter number of persons covered in figures and words","type":"text","label":"No. of persons covered (including proposer) (in figure), (in words)","options":[],"required":true,"pdf_field":""},{"help":"Customer code if available","type":"text","label":"Customer Code","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Particulars","fields":[{"help":"Indicate if any existing base policy covers insured persons","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":"Write 'Yes' if cover required; cover available up to sum insured graded year wise","type":"choice","label":"Diabetes","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write 'Yes' if cover required; cover available up to sum insured graded year wise","type":"choice","label":"Hypertension","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Write limit of cover required; available limits per family as listed","type":"choice","label":"Outpatient Treatment","options":["₹ 2,000","₹ 3,000","₹ 4,000","₹ 5,000","₹ 10,000"],"required":false,"pdf_field":""},{"help":"Write benefit amount required per individual; amount should not exceed sum insured under policy","type":"choice","label":"Critical Illness","options":["₹ 2,00,000","₹ 3,00,000","₹ 5,00,000","₹ 10,00,000"],"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, specify"],"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 complete","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":"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":"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","fields":[{"help":"Name of insured person undergoing medical exam","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":true,"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":true,"pdf_field":""},{"help":"List medications and duration","type":"text","label":"Details of present and past medication with duration","options":[],"required":true,"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":true,"pdf_field":""},{"help":"Findings of general examination","type":"text","label":"General examination","options":[],"required":true,"pdf_field":""},{"help":"Findings of systematic examination","type":"text","label":"Systematic examination","options":[],"required":true,"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 on medical 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 persons","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":"Provide 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":"Provide 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":"Explain reasons 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":"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 for portability form","type":"signature","label":"Signature of the policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Annexure C: Documents Required","fields":[{"help":"Attach all listed documents as applicable","type":"attachment","label":"List of documents required","options":[],"required":true,"pdf_field":""}],"filled_by":""}],"deadlines":[],"applies_to":"New National Parivar Mediclaim 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 insurer is authorized to seek medical and insurance information for underwriting and claims.","The insurer may share proposal and medical information with government or regulatory authorities.","Incorrect information may lead to policy voidance and forfeiture of premium."],"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/892-new-national-parivar-mediclaim-policy-proposal-form"}