{"id":950,"title":"NEW INDIA PREMIER MEDICLAIM POLICY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"new-india-assurance","name":"The New India Assurance Company Limited"},"source_pdf":"https://www.newindia.co.in/assets/docs/know-more/health/new-premier-mediclaim-claim-policy/New%20India%20Premier%20Mediclaim%20Proposal%20Form.pdf","sha256":"c9bb9eb71477b23fc332ff0e2e75c762d2cde281484058b4bd4c91f12d4adb0d","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for health insurance coverage under the New India Premier Mediclaim Policy. The proposer fills it to provide personal, health, and insurance details for underwriting.","notes":["Persons above 50 years or with adverse medical history must undergo pre-acceptance health checkup.","Non-disclosure or misleading information will nullify the policy cover.","By default, policy documents will be sent to registered email unless physical copy is requested.","Use original documents and provide accurate information.","Cancelled cheque must be of the same bank account for NEFT payments.","If cancelled cheque does not bear account holder’s name, provide bank statement or get bank attestation.","NEFT form must be complete in all respects.","Policy holder’s name must exactly match bank account records for electronic payments."],"title":"NEW INDIA PREMIER MEDICLAIM POLICY PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Agency Details","fields":[{"help":"","type":"text","label":"Name of the Intermediary","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proposer’s Details","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Educational qualifications","options":[],"required":false,"pdf_field":""},{"help":"Enter monthly income in INR","type":"amount","label":"Family Monthly Income","options":[],"required":false,"pdf_field":""},{"help":"Provide any one valid identity number","type":"text","label":"Aadhar card No / Passport No / Pan card No","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Landline / Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Full permanent address","type":"text","label":"Residential Address (Permanent)","options":[],"required":true,"pdf_field":""},{"help":"Address where communication should be sent","type":"text","label":"Address for Correspondence","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Family Physician","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Preferred Communication","fields":[{"help":"Preferred phone number for communication","type":"phone","label":"Phone","options":[],"required":false,"pdf_field":""},{"help":"Preferred email for communication","type":"email","label":"Mail","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Members to be Insured","fields":[{"help":"Enter name of proposer and insured members","type":"table","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Occupation of each insured member","type":"table","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of each insured member","type":"table","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Gender of each insured member","type":"table","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Height in centimeters","type":"table","label":"Height in Cms","options":[],"required":false,"pdf_field":""},{"help":"Weight in kilograms","type":"table","label":"Weight Kgs","options":[],"required":false,"pdf_field":""},{"help":"Contact number or details","type":"table","label":"Contact Details","options":[],"required":false,"pdf_field":""},{"help":"ID number for each insured member","type":"table","label":"Identity Document Number","options":[],"required":true,"pdf_field":""},{"help":"Type of identity document (Aadhar, Passport, PAN, etc.)","type":"table","label":"Nature of ID","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"ABHA Number / ABHA ID and Consent","fields":[{"help":"Name of insured member","type":"table","label":"Member name","options":[],"required":false,"pdf_field":""},{"help":"Enter 14 digit ABHA number if available","type":"table","label":"ABHA Number (14 digits)","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no for each member","type":"checkbox","label":"Consent to share Medical records with Insurers / TPA’s through ABHA","options":["YES","NO"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Name of nominee(s)","type":"table","label":"NAME","options":[],"required":true,"pdf_field":""},{"help":"Relationship of nominee to proposer","type":"table","label":"Relation","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of nominee","type":"table","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Name of appointee if nominee is minor","type":"table","label":"Appointee Name (If the Nominee is minor)","options":[],"required":false,"pdf_field":""},{"help":"Relationship of appointee with minor nominee","type":"table","label":"Relationship with Minor (Nominee)","options":[],"required":false,"pdf_field":""},{"help":"Percentage share of nominee; if only one nominee, share is 100%","type":"table","label":"% Share nominee is entitled to","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Period of Insurance","fields":[{"help":"Start date of insurance coverage","type":"date","label":"From","options":[],"required":true,"pdf_field":""},{"help":"End date of insurance coverage","type":"date","label":"To","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Opted","fields":[{"help":"Select sum insured amount for Plan A","type":"choice","label":"Plan A","options":["15,00,000","25,00,000","50,00,000","1,00,00,000"],"required":true,"pdf_field":""},{"help":"Select sum insured amount for Plan B","type":"choice","label":"Plan B","options":["15,00,000","25,00,000","50,00,000","1,00,00,000"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Riders Table (YES/NO)","fields":[{"help":"Tick yes or no for each insured member","type":"checkbox","label":"Critical Illness Rider","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick yes or no for each insured member","type":"checkbox","label":"Pre and Post Hospitalization Rider","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick yes or no for each insured member","type":"checkbox","label":"Durable Medical Devices Rider","options":["YES","NO"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of existing / past insurance","fields":[{"help":"","type":"yes-no","label":"Have you OR any other persons proposed for this insurance ever been covered under any health insurance of any insurance company? If yes, please provide policy details.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of insured persons with past insurance","type":"table","label":"Name of Insured","options":[],"required":false,"pdf_field":""},{"help":"Name of insurance company","type":"table","label":"Name of Insurer","options":[],"required":false,"pdf_field":""},{"help":"Policy number or details","type":"table","label":"Policy Details","options":[],"required":false,"pdf_field":""},{"help":"Sum insured amount","type":"table","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Start date of first policy","type":"table","label":"Period First Policy Inception Date","options":[],"required":false,"pdf_field":""},{"help":"Claims history","type":"table","label":"Claims, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any insurance company refused or declined a proposal for medical insurance for you or any other persons proposed to be Insured in the past? If yes, the details thereof.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of person refused insurance","type":"text","label":"Name of the Insured","options":[],"required":false,"pdf_field":""},{"help":"Reason insurance was refused","type":"text","label":"Reasons for refusal","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical history of proposer / Insured Person","fields":[{"help":"","type":"yes-no","label":"Is the Proposer / Insured Person currently in good health? Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"For past 4 years has the person to be insured consulted any physician for treatment or medical investigation or surgical operation","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Is any Insured Person suffering from Heart disease, Diabetes/raised Blood sugar, High Blood pressure / Hypertension, Circulatory disease","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Has any treatment been taken in the past for Paralysis, cancer, disease of kidney, stomach, intestine, brain, lung or joint disorder, mental Illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Has anyone in the past suffered from Congenital stroke, birth defect, physical deformity, or HIV/AIDS","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Have you suffered in the past for Disorders of the eye, ears, nose or throat, gland disorder such as Thyroid, Blood disorder or disorder of the urinary system","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Has any person proposed for Insurance had signs or symptoms or was diagnosed or received Medical Advice / Treatment in respect of any condition, aliment or Injury or related condition in the past 36 months?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"table","label":"Any other illness, impairment, disability or surgery not mentioned above","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide name, illness with symptoms, treatment details with doctor’s details, and outcome of treatment","type":"table","label":"If you have answered Yes to any of the above questions, please furnish the details as below:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Document Delivery Preference","fields":[{"help":"By default policy documents will be shared to your registered email ID","type":"checkbox","label":"Please Tick ☐ if you wish to receive the physical copy.","options":["Tick if physical copy desired"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Sign and date the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Photographs and Signatures of Proposer and Insured Members","fields":[{"help":"Attach recent photo","type":"photo","label":"Proposer Photo","options":[],"required":true,"pdf_field":""},{"help":"Attach recent photo","type":"photo","label":"Insured 2 Photo","options":[],"required":false,"pdf_field":""},{"help":"Attach recent photo","type":"photo","label":"Insured 3 Photo","options":[],"required":false,"pdf_field":""},{"help":"Attach recent photo","type":"photo","label":"Insured 4 Photo","options":[],"required":false,"pdf_field":""},{"help":"Attach recent photo","type":"photo","label":"Insured 5 Photo","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"NEFT Bank Details","fields":[{"help":"Name as per bank records","type":"text","label":"Name (As in Bank Account)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Branch","options":[],"required":true,"pdf_field":""},{"help":"Account number for electronic fund transfer","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Magnetic Ink Character Recognition number","type":"text","label":"MICR No","options":[],"required":true,"pdf_field":""},{"help":"11 digit IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm bank details","type":"signature","label":"Proposer/Policy holder’s signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"New India Premier Mediclaim Policy","attachments":["Cancelled cheque for NEFT bank account","Photocopy of bank statement / passbook with latest entries if cancelled cheque does not bear account holder’s name","Bank attested NEFT mandate if required"],"declarations":["The information provided in this proposal is true and complete to the best of my knowledge.","The policy will come into force only after full receipt of the premium.","I will notify any change in occupation or health after submission but before acceptance.","I consent to the company seeking medical information from doctors, hospitals, employers, and other insurers for underwriting and claims.","I authorize the company to share my proposal and medical records with insurers, TPAs, government, and regulatory authorities for underwriting and claims."],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"1800-209-1415","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/","quote":"Login\nCustomer\nIntermediary\nToll Free :\n1800-209-1415\nAbout Us\nOverview\nProfile\nManagement\nFinancials\nWorkforce\nOur Offices\nIntermediary\nInvestors\nProducts\nAll Products\nBase","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@newindia.co.in","label":"Grievance Redressal Officer Ms. V. Akila","level":1,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/grievance","quote":"dressal Officer\nName\nDesignation\nEmail ID\nLandline No\nMs. V. Akila\nDeputy General Manager & Grievance Redressal Officer\ngro@newindia.co.in\n022-2270 8316\nKnow Your Customer Care Officers\nNote :\nPlease select type \"City Name or Policy No\" to know your Grievanc","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customercare.ho@newindia.co.in","label":"Customer Service Desk Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/STANDARD%20FORM%20FOR%20TWO%20WHEELERS%20BASE%20PACKAGE%20POLICY.pdf","quote":"complaint, please free to call our 24X7 Toll free number 1800-209-1415 or you may email to the customer service desk at customercare.ho@newindia.co.in. After investigating the matter internally and subsequent closure, we will send our response.\nYou can also approach the","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-1415","label":"Toll Free","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/grievance","quote":"Grievance New India Assurance Co. Ltd.\nLogin\nCustomer\nIntermediary\nToll Free :\n1800-209-1415\nAbout Us\nOverview\nProfile\nManagement\nFinancials\nWorkforce\nOur Offices\nIntermediary\nInvestors\nProducts\nAll Products\nBase","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://www.newindia.co.in/portal/readMore/Grievances","label":"Customer Grievance Redressal Website","level":null,"hours":null,"applies_to":"all","source_url":"https://www.newindia.co.in/assets/docs/know-more/motor/Customer%20Information%20Sheet%20%28CIS%29%20Two%20Wheeler%20Package%20Policy.pdf","quote":"sal and Policyholders Protection | ln case of any grievance the insured person may contact the company through Website: https://www.newindia.co.in/portal/readMore/Grievances Toll free: 1800-209-1415 Visit the Servicing Branch mentioned in the policy Document Insurance Ombudsman If You are sti","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/new-india-assurance/950-new-india-premier-mediclaim-policy-proposal-form"}