PROPOSAL FORM

Agent Code: Application no:

This is an application for insurance and issuance of this does not amount to acceptance of proposal by us. Commencement of risk under
this proposal is subject to acceptance of the risk by us and receipt of premium. The information declared by you in this form is the basis for
issuance of the policy. Please answer all questions carefully. Any incomplete, incorrect or partially correct answers may lead to rejection of
the proposal and also might lead to cancelation of policy.
CAPITAL LETTERS

1. PROPOSER’S DETAILS

Name (Mr/Mrs/Ms/Dr):
First Name Middle Name Surname
Marital Status:
Married Single OthersGender: Male Female
D D M M Y Y Y Y Occupation: Pvt Service Govt
Date of Birth:
Business
Unique ID Service
Mobile: OR Voter’s ID

PAN Card*:

Income(in lakhs) Upto 3

Address:

Landmark

Area
District
City/Town
State
Pin Code
*Pan card

2. PLAN DETAILS
D D M M Y Y Y Y
Proposed Policy Period: D D M M Y Y Y Y t

Sum insured type: Floater Individual Room Category:

Shared Accommodation

Riders shall be opted by all the eligible members. There cannot be selection between the eligible members for choosing riders.

3. DETAILS OF THE PERSON(S) TO BE INSURED

Sl Name of the Gender Relationship Date of Birth Height Weight Sum

with Proposer* Unique ID #
No. Insured Person M/F D|D|M|M|Y YYY cms kgs Insured

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1800 266 7780 OR 1800 229966 (For Senior Citizens)
 Application no:

4. NOMINEE DETAILS
In the event of the death of the Proposer any payment due under the Policy shall become payable to the nominee in accordance with the
Policy terms and conditions

Nominee Name Date of birth* Relationship Address of the Nominee

The nominee must be an immediate relative of the Proposer.

*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:
Appointee Name Relationship Address of the Appointee

5. EXISTING/PREVIOUS INSURER DETAILS

Is the proposer or any of the persons proposed, already Insured under a health plan with Tata AIG General Insurance Company Ltd. or any
other insurer or is a proposal pending for Policy issuance?

If yes, please indicate the Policy/Application number(s):

Since when continuously insured: D D M M Y Y Y Y

Do you want Us to consider these details for portability*Yes No

insurance policy copies.

Period of Insurance SI &

Policy No. Name of Insurer Cumulative Claims
Insured person From To lodged*
D|D|M|M|Y YYY D|D|M|M|Y YYY
bonus / Rs.

4128i/iHPN/132577039/03/000

4128i/iHP/132577039/02/000

4128i/iHPN/132577039/01/000

4128i/iHP/132577039/00/000

*during the preceding years along with the diagnosis

6. MEDICAL AND LIFESTYLE DETAILS

A. Medical History :
Please answer the below mentioned questions individually in Yes(Y) / No (N):
You must answer the questions truthfully. Not doing so would lead to termination of your policy.

Please answer each of the following questions individually for each Insured Person
3 4

to take investigations / medication / surgery or undergone a surgery for the following medical conditions?

Chest Pain / Heart Disease

Y Y Y Y Y Y Y
Arthritis
Y Y Y Y Y Y Y
COPD
Y Y Y Y Y Y Y
Kidney Failure, Dialysis

Liver Cirrhosis/Hepatitis B or C Y Y Y Y Y Y Y
Cancer
Y Y Y Y Y Y Y
HIV/AIDs/STDs
Y Y Y Y Y Y Y
Stroke, Epilepsy, Paralysis
Y Y Y Y Y Y Y
Psychiatric, Mental Illness or disorder
Y Y Y Y Y Y Y
Ulcerative Colitis/Crohn’s disease
Y Y Y Y Y Y Y

Y Y Y Y Y Y Y

2 Y Y Y Y Y Y Y
1800 266 7780 OR 1800 229966 (For Senior Citizens)
 Application no:

Any other illness/disease/injury/disability in the past other than for

Y Y Y Y Y Y Y

Are you or any persons proposed on regular medication (including any

Ayurvedic treatment) or awaiting any procedure/treatment? Y Y Y Y Y Y/N Y
Have you ever been diagnosed with any of these medical conditions
with
Y Y Y Y Y Y Y

Diabetes/ Elevated Blood Pressure/ Hypertension/

High Cholesterol/ Hypothyroidism

Y Y Y Y Y Y Y
date of delivery (EDD). Any history of pregnancy related complications?

D D M M Y Y Y Y
EDD:
Has any application for life, Health or critical illness insurance ever
been declined, postponed, loaded or been made subject to any special Y Y Y Y Y Y Y
conditions by any insurance company?
Has any health or life insurance policy ever been terminated in the past? Y Y Y Y/N Y Y/N Y

B. Detailed information in case any of the questions in section 6 (A) is ticked ‘Yes’.
(Please send us medical documents along with this application form.)
Diagnosis as per Diagnosis date/ Date of last Doctor/Hospital
Insured Name Treatment details
documents Surgery Date consultation Name and Ph No.

C. Lifestyle Information
Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes No
If yes please indicate the name and quantity per day.

Insured Person
3 4

Smoking (No of Cigarettes or Bidis/day)

Others habit forming substances/addictive (Quantity consumed)

7. PAYMENT DETAILS

Premium Payer:

Relationship:

Premium Amount (Rs):

Instrument type: Cash Cheque Debit Card Credit Card Others

Sources of funds: Salary Business Other

Please make a Crossed Cheque/DD/Pay Order in favour of ‘Tata AIG General Insurance Company Limited’ only.
AML guidelines:

3. The insurance company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of
law under any of the statutes, directly or indirectly governing the prevention of money laundering in India.
Nationality : Indian No
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1800 266 7780 OR 1800 229966 (For Senior Citizens) [email protected]

www.tataaig.com
 Application no:

Type of Organization making the payment (Pls tick)

Limited company Society
Trust Partnership Cooperatives
Signature of Proposer: Date:
8. BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)
Funds Transfer (NEFT) / Real Time Gross Settlement (RGTS) / Interbank Mobile Payment Service (IMPS)
For this purpose, please submit the following details of the proposer’s bank account.
Name of the account holder
Name of the bank
Branch Bank
Account no.
Bank IFSC code
Account Type SB Account Current Account Others (please specify)

9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or
of these other persons.
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 insurer and that the policy will come into force only after full payment of the premium chargeable.
I further declare that I 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.
I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended
health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on
the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
I have understood the purpose of Aadhar authentication and hereby state that I have no objection in providing my Aadhar details.
Signature of Proposer: Date:

Limited to send all my policy and service related communication to the email id as mentioned in this application form.
10. DECLARATION/VERNACULAR DECLARATION

Signature of Proposer: Code:

Name & Signature of agent/intermediary:

Signature/Thumb impression of the Proposer Name & Signature of agent/intermediary

11. AGENT DECLARATION

I, (Full Name) in my capacity as an

including statement(s), information and response(s) submitted by him/her in this Proposal Form to questions contained herein or any details
sought herein will form the basis of the Contract of Insurance between the Company and the Proposer, if this Proposal is accepted by the
Company

may be treated by the Company as null and void and all premiums paid under the Policy may be forfeited to the company.

License No. (Intermediary/Corporate

Signature of Agent: Place: Date:

12. Prohibition of Rebates - Section 41 of Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
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 or renewing or continuing a policy accept any rebate,

13. FOR OFFICE USE ONLY

Intermediary Code and Name:
Branch Receipt Date: Channel Type:
Business type: Urban Rural Social Customer ID:
Insurance is the subject matter of solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.
 Application no:

1800 266 7780 OR 1800 229966 (For Senior Citizens)

 Application no:

Date :
ACKNOWLEDGEMENT

Name of the Proposer:

We acknowledge with thanks the receipt of your application for Tata AIG MediCare and amount by

Cash
Cheque Demand Draft Others of amount of Rs.

Neither the submission to us of a completed proposal for insurance nor any payment towards this application obliges us to agree to issue a policy, which decision
is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions and we shall

Tata AIG General Insurance Company Limited.

1800 266 7780 OR 1800 229966 (For Senior Citizens) [email protected]

www.tataaig.com