{"id":958,"title":"PROPOSAL FORM FOR JANATA MEDICLAIM POLICY","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/janata-mediclaim-policy/revised%20Janata%20Mediclaim%20Proposal%20Form%20.pdf","sha256":"366f7bf6cb4d216775b1f96f0d46d24bbbe7471785e02e5229b267831c88031c","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Janata Mediclaim insurance policy from The New India Assurance Co. Ltd. It collects personal, medical, and family details to assess the insurance risk.","notes":["Read the prospectus before filling the form.","Pre-acceptance health check-up is required for persons above 45 years or with adverse medical history.","Fresh proposal form and medical check-up required if there is a break in insurance cover or enhancement in sum insured.","Non-disclosure, misleading information, fraud or non-cooperation will nullify the cover.","Policy documents will be sent to registered email by default unless physical copy is requested.","Use block letters where applicable.","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/passbook or bank attestation.","NEFT form must be complete in all respects.","Policy holder’s name in policy must exactly match bank account name for electronic payments."],"title":"PROPOSAL FORM FOR JANATA MEDICLAIM POLICY","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name of the proposer","type":"text","label":"NAME OF PROPOSER : Mr./Mrs.","options":[],"required":true,"pdf_field":""},{"help":"Enter full residential address","type":"text","label":"RESIDENTIAL ADDRESS :","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Tel. No. :","options":[],"required":false,"pdf_field":""},{"help":"Enter fax number if any","type":"phone","label":"Fax No. :","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-Mail :","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate occupation","type":"choice","label":"Occupation: (please Tick)","options":["Professional/Administrative/Managerial","Business /Traders","Clerical, Supervisory and related workers","Hospitality and Support Workers","Production Workers, Skilled and non-Agricultural Labourers","Farmers and Agricultural Workers","Police/Para Military/Defence","Housewives","Retired Persons","Students - School and College","Any Other"],"required":true,"pdf_field":""},{"help":"Enter average monthly income in rupees","type":"amount","label":"Average Monthly Income Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Income Tax PAN No.:","options":[],"required":false,"pdf_field":""},{"help":"Provide family physician's contact details","type":"text","label":"NAME, ADDRESS & TEL. NO. : OF FAMILY PHYSICIAN","options":[],"required":false,"pdf_field":""},{"help":"Physician's qualification","type":"text","label":"QUALIFICATION :","options":[],"required":false,"pdf_field":""},{"help":"Physician's registration number","type":"text","label":"REGN. NO :","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no and submit proof if yes","type":"yes-no","label":"Are you a member of Recognized Health Club/Gymnasium:","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Insurance Details","fields":[{"help":"Fill details for each insurance: Name of Insurer, Insurance Scheme, Policy No., Period of cover, Claim Amt. Recd./receivable","type":"table","label":"Are you at present or have you been at any other time in the past covered under any other Insurance (PA, Cancer Insurance, Hospitalization Insurance or other Medical Insurance). If so, give particulars of:","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium charged. If so, give details:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Persons to be Insured","fields":[{"help":"Provide for each person: Name, Date of Birth, Age, Sex (M/F), Relation with Proposer, Sum Insured selected, History of Diabetes, Hypertension (tick)","type":"table","label":"DETAILS OF PERSONS TO BE INSURED:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"For each nominee: NAME, Relation, Date of Birth, Appointee Name (if nominee is minor), Relationship with Minor, % Share nominee is entitled to","type":"table","label":"Nominee Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Document Delivery Preference","fields":[{"help":"Tick if physical policy documents are preferred; otherwise documents will be sent to registered email","type":"checkbox","label":"Please Tick ☐ if you wish to receive the physical copy.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical History","fields":[{"help":"Answer yes or no and provide details if no","type":"yes-no","label":"Are all the members proposed for insurance in good health and free from physical and Mental disease or infirmity? If no, give details of the illnesses/ diseases for each member.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick applicable pre-existing diseases for each person","type":"table","label":"Nature of illness / pre-existing diseases (*)","options":["Ischaemic Heart Disease","Hypertension","Diabetes Mellitus","Spinal or Vertebral Disorders","Cataract","Breathing Disorders","Uterine Bleeding","Arthritis and Joint disorders","Gastritis and Duodenitis","Kidney disorders","Headache Syndromes","Hernia","Stroke and T.I.A.","Thyroid and Other Hormonal Disorders","E.N.T. Disorders","Cholelithiasis","Any Malignancy","Hemorrhoids","Enlargement of Prostate (BPH, enlargement of prostate)","Any Other (Please specify)"],"required":false,"pdf_field":""},{"help":"For each person: Name, Nature of Illness/disease/injury & treatment received, Date on which first treatment taken, First treatment completed/is continuing, Name of attending medical practitioner/surgeon with address & Tel.Nos.","type":"table","label":"Has any of the persons proposed for insurance has suffered from any illness/disease or had an accident in the past? If so, give details as under:","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Are there any additional facts affecting the proposed Insurance, which should be disclosed to insurers? If yes, then give details below:","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Please give details of any knowledge or any positive existence or presence of any ailment, sickness or injury, which may require medical attention? If yes, then give details below:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"ABHA Number / ABHA ID and Consent","fields":[{"help":"Enter name of each member","type":"text","label":"Member name","options":[],"required":false,"pdf_field":""},{"help":"Enter 14 digit ABHA number for each member","type":"text","label":"ABHA Number (14 digits)","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no for each member","type":"choice","label":"Consent to share Medical records with Insurers / TPA’s through ABHA ☐ YES / ☐ NO","options":["YES","NO"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Period of Insurance","fields":[{"help":"Enter start date of insurance period","type":"date","label":"Period of Insurance : From","options":[],"required":true,"pdf_field":""},{"help":"Enter end date of insurance period","type":"date","label":"To","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Read and agree to the declaration about truthfulness and consent to medical information access","type":"text","label":"Declaration","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"NEFT Bank Details for Payment","fields":[{"help":"Enter bank account holder name","type":"text","label":"Name(As in Bank Account)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Name of Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR number","type":"text","label":"MICR No","options":[],"required":true,"pdf_field":""},{"help":"Enter 11-digit IFSC code for NEFT","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Janata Mediclaim Policy","attachments":["Two Stamp size photograph of each person to be insured (one to be affixed on the proposal)","Proof of membership of Recognized Health Club/Gymnasium (if applicable)","Cancelled cheque for NEFT bank details or bank attested NEFT mandate or bank statement/passbook copy with account holder name"],"declarations":["The persons proposed for insurance are family members not engaged in high risk occupation.","None of the insured suffer from any pre-existing conditions except as declared.","The proposer consents to insurer seeking medical information from any hospital or medical practitioner.","The proposal form and its statements form the basis of the insurance contract.","If any information is found incorrect or untrue, the insurer shall incur no liability under this insurance."],"dropped_labels":0},"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/958-proposal-form-for-janata-mediclaim-policy"}