Proposal Form For New India Premier Mediclaim

THE NEW INDIA ASSURANCE CO. LTD.
REGISTERED & HEAD OFFICE: 87, MAHATMA GANDHI ROAD, MUMBAI 400001
IRDAI Registration No: 190
NEW INDIA PREMIER MEDICLAIM POLICY

PROPOSAL FORM
Agency Details
Name of the Intermediary

Intermediary Code
Mobile Number
Email ID
The Liability of the company does not commence until the proposal has been accepted and
premium has been paid.
This Proposal is the basis for this Policy and any subsequent Renewals that we issue to You and it is
therefore necessary that You provide all the information in this Proposal fully and accurately which
is material to the acceptance of the risk.
Persons above 50 years of age or persons below 50 years of age having adverse medical history
declared in the proposal form will have to undergo pre-acceptance health checkup at a designated
hospital/nursing home.
Non-disclosure of facts material to the assessment of the risk, providing misleading information,
fraud or non-co-operation by the insured will nullify the cover under the policy.
1. Proposers Details:
Name
Gender
Occupation
Educational qualifications
Family Monthly Income
Aadhar card No / Passport No /
Pan card No
Landline / Mobile Number
Residential Address ( Permanent )
Address for Correspondence
Email ID
Name of Family Physician
IRDAI/HLT/NIA/P-H/V.I/46/2016-17 Page 1 of 6
2. In case of any communication, you would prefer to be contacted by phone, email?
Phone: Mail:
3. Details of Members to be Insured:
Proposer Insured 2 Insured 3 Insured 4 Insured 5 Insured 6

Name
Occupation
Date of Birth
Gender
Height in
Cms
Weight Kgs
Contact
Details
Identity
Document
Number
Nature of ID
4. Name of the Nominee ________________________________ Relationship ________________

5. Period of Insurance: From To
6. Plan and Sum Insured Opted:
Plan A Plan B
Sum Insured Sum Insured
15,00,000 50,00,000
25,00,000 1,00,00,000
7. Details of existing / past insurance:

i) 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.
Name of Name of Policy Sum Period First Policy Claims ,if

Insured Insurer Details Insured Inception any
Date
ii) 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.
Name of the Insured Reasons for refusal:
8. Medical history of proposer / Insured Person:

i) Is the Proposer / Insured Person currently in good health?
Yes No
ii) Please provide Yes / No for the following questions in the table below for all Insured
Persons
Questions Proposer Insured 1 Insured 2 Insured 3 Insured 4 Insured 5

For past 4 years has the
person to be insured
consulted any physician for
treatment or medical
investigation or surgical
operation,
Is any Insured Person
suffering from Heart
disease, Diabetes/raised
Blood sugar, High Blood
pressure/Hypertension,
Circulatory disease
Has any treatment been
taken in the past for
Paralysis, cancer, disease of
kidney, stomach, intestine,
brain, lung or joint disorder,
mental Illness
Has anyone in the past
suffered from Congenital
stroke, birth defect,
physical deformity, or
HIV/AIDS
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
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?
Any other illness,
impairment , disability or
surgery not mentioned
above
iii) If you have answered Yes to any of the above questions , please furnish the details as
below:
Sr. No. Name of Proposed Specify Illness Treatment details Outcome of

Insured with symptoms with treating treatment ( e.g.
Doctors details ongoing , complete
recovery, recurrent
or likely to recur
9. Declaration:
I declare that the persons proposed for insurance are my family members and I also declare that
(STRIKE OUT ONE OF THESE TWO STATEMENTS THAT IS NOT APPLICABLE)
i. None of them suffer from any pre-existing conditions Yes No

ii. I have given explicit information of such sickness/disease/injury sustained in
Yes No
the above columns where the information has been sought.
1. I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the
above statements, answers and/or particulars given by me are true and complete in all respects to
the best of my knowledge and that I/We am/are authorized to propose on behalf of these other
persons.
2. I understand that the information provided by me will form the basis of the insurance policy, is
subject to the Board approved underwriting policy of the insurance company and that the policy will
come into force only after full receipt of the premium chargeable.
3. I/We further declare that I/we will notify in writing any change occurring in the occupation or
general health of the life to be insured/proposer after the proposal has been submitted but before
communication of the risk acceptance by the company.
4. I/We declare and consent to the company seeking medical information from any doctor or from a
hospital who at any time has attended on the life to be insured/proposer or from any past or present
employer concerning anything which affects the physical or mental health of the life to be
assured/proposer and seeking information from any insurance company to which an application for
insurance on the life to be assured/proposer has been made for the purpose of underwriting the
proposal and/or claim settlement.
5. I/We authorize the company to share information pertaining to my proposal including the medical
records for the sole purpose of proposal underwriting and/or claims settlement and with any
Governmental and/or Regulatory authority.
Signature of Proposer __________________________________
Date: __________/_________/_________ Place: __________________________
Photo Photo
Proposer
Insured 2 Insured 3
Signature Signature Signature
Photo Photo Photo

Insured 4 Insured 5 Insured 6
Signature Signature Signature
Section 41 of Insurance Act, 1938
Prohibition of Rebates
No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take
out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any
rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy,
nor shall any person taking out of renewing or continuing a policy accept any rebate except such rebate as
may be allowed in accordance with the prospectus or table of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may
extend to ten lac rupees.
FOR OFFICE USE ONLY:
S Name of insured Date of Sex BMI Sum

Relation Occupation Premium
No person Birth M/F Insured
1
2
3
4
5
6
Remarks of Underwriter: Total:
Service Tax
Gross Total
DETAILS OF INTERMEDIARY (AGENT / BROKER / DIRECT)

Name :
Code :

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THE NEW INDIA ASSURANCE CO. LTD.

NEW INDIA PREMIER MEDICLAIM POLICY

Name of the Intermediary

Proposer Insured 2 Insured 3 Insured 4 Insured 5 Insured 6

4. Name of the Nominee ________________________________ Relationship ________________

7. Details of existing / past insurance:

Name of Name of Policy Sum Period First Policy Claims ,if

Name of the Insured Reasons for refusal:

8. Medical history of proposer / Insured Person:

Questions Proposer Insured 1 Insured 2 Insured 3 Insured 4 Insured 5

Sr. No. Name of Proposed Specify Illness Treatment details Outcome of

i. None of them suffer from any pre-existing conditions Yes No

Signature of Proposer __________________________________

Date: __________/_________/_________ Place: __________________________

Signature Signature Signature

Photo Photo Photo

Signature Signature Signature

FOR OFFICE USE ONLY:

S Name of insured Date of Sex BMI Sum

DETAILS OF INTERMEDIARY (AGENT / BROKER / DIRECT)

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4. Name of the Nominee ________________ Relationship

Date: ______/_/_ Place: ______________________