AROGYA SANJEEVANI POLICY, ICICI LOMBARD

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UIN No: ICIHLIP20178V011920

AROGYA SANJEEVANI POLICY, ICICI LOMBARD PROPOSAL FORM

For Official Use Only
Product Code: 4171 Proposal No. :
Intermediary ID : Intermediary Name :
Branch Name : Deal No. :

GUIDELINES FOR COMPLETION OF THE FORM (To be filled by proposer)

Please answer all the questions fully and correctly. Where any question does not apply, please mention clearly that the same is not applicable.
Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not to suppress any material facts in response to the questions in
the proposal form. Please disclose all material facts while filing in the proposal form.
The Policy shall become void at the option of Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any material
particular in the proposal form/personal statement, declaration and connected documents or any material information having been withheld by the Proposer or any one acting on
his behalf. Kindly contact the Company’s Offices or Agents for any doubts or clarifications on the proposal form.
Terms and Conditions
• Initial waiting period of 30 days for all illnesses (except Hospitalization due to injury or Accident).
• Specific waiting period of first two/four years for specific illnesses and treatments (mentioned in the policy wording).
• Pre- existing conditions/ diseases declared and accepted by Us will be covered immediately after 48 months of continuous coverage under the policy.
• Sum Insured can be changed at the time of renewal only. Company reserves right to approve/reject the change in Sum Insured. Fresh waiting period as per the terms of the
policy will be applicable to the enhanced limit from the effective date of such enhancement.
• Factors determining the renewal premium are (i) age slab of the senior most insured member at the time of renewal (ii)any change in the renewing policy.
• The liability of the Company does not commence until this Proposal has been accepted by the Company and premium realised.

Signature of proposer/customer: Date: D D / M M / Y Y Y Y Place:____________________________

PROPOSER / CUSTOMER INFORMATION Please fill all the particulars in CAPITAL letters only
Proposer’s Name (please leave a space after each part of name)
Mr. / Ms. / Dr. : F I R S T M I D D L E L A S T
Date of Birth : D D M M / Y Y Y Y
/ Gender : Male Female Third gender
Marital Status : Single Married Divorced Widowed Separated
Occupation : Salaried Self Employed Professional Retired Housewife Student Unorganized Sector
Informal Sector Others Details
Nationality: Indian Others (please specify) _______________ Residential Status: Indian Resident Non Resident Indian
Educational Qualifications: Lesser than matriculation Matriculation Graduate Post-graduate Professional Course
Annual Income : Up to 1.8 lacs Between 1.9 to 5 Lacs Between 5 - 10 Lacs Between 10 - 20 Lacs 20 Lacs and above
Differently abled (PWD) Yes No
GST Number: (If Applicable)
PAN Card No.: Passport No. Aadhaar No.
Correspondence Address :
Landmark :
City : State : Pin code :
Landline Number (with STD Code) : Mobile Number* :
E-mail address :
Permanent Residence Address :
Landmark :
City : State : Pin code :
Are You or any of Your family members proposed to be insured are politically exposed person** . Yes No
If yes, Please provide details ____________________________________________________________________________________________________
**Politically Exposed Persons are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States/Governments,
senior politicians, senior government/judicial/military officers, senior executives of state-owned corporations, important political party officials, etc.
*Kindly provide the details to enable us to serve you better.
NOMINEE DETAILS
Name of Nominee : Date of Birth : D D / M M / Y Y Y Y
Relationship :

DETAILS OF APPOINTEE (Details to be filled only if nominee is a minor)

Appointee Name : Relationship with Proposer :

FAMILY PHYSICIAN DETAILS

Name of Physician : F I R S T M I D D L E L A S T
Landline Number (with STD Code) : Mobile Number :
 DETAILS OF PERSONS TO BE INSURED

Insured Gender Date of Birth Relationship Height Weight

Full Name (First, Middle, Last) PAN No.
No. (M/F/T) (DD/MM/YY) with Proposer (feet/inch) (kgs)
1. / /
2. / /
3. / /
4. / /
5. / /
Are all insured Indian nationals and Indian residents? Yes No If Not, please provide details:
DETAILS OF OTHER HEALTH INSURANCE POLICIES IN EXISTENCE
Is any proposer or the person proposed, already insured under a plan with ICICI Lombard GIC Ltd? Yes No
If yes please indicate below the Policy number(s) (Please mention proposal number in case of pending proposal.)
Insured Name Policy No. / Proposal No. Period of Insurance Sum Insured Claims lodged during policy period (Yes/No)

DETAILS OF THE INSURANCE PRODUCT/ PLANS

Please fill the form as per your health care needs.
AROGYA SANJEEVANI POLICY, ICICI LOMBARD

Individual Plan Individual 1A + 1C 1A + 2C

Tenure 1 Year Plan Type Options
Floater 2A 2A+1C 2A + 2C 2A + 3C

` 50,000 1 Lakh 1.5 Lakhs 2 Lakhs 2.5 Lakhs 3 Lakhs 3.5 Lakhs 4 Lakhs 4.5 Lakhs
Sum Insured 5 Lakhs 5.5 Lakhs 6 Lakhs 6.5 Lakhs 7 Lakhs 7.5 Lakhs 8 Lakhs 8.5 Lakhs 9 Lakhs
9.5 Lakhs 10 Lakhs
Medical Underwriting Required for person aged 46 years and above.
Cost of Pre Policy Medical Check-up for policy issuance: 100% of the pre policy medical test cost will be paid by the Company. In case the health proposal is
declined, medical cost will be deducted from the premium and the balance would be refunded.

PREMIUM PAYMENT IN INSTALLMENTS

Monthly Quarterly Semi Annually Annually

PAYMENT DETAILS
Payment Option: Cheque DD Cheque/ DD Number: Dated: D D / M M / Y Y Y Y

Premium Amount: Amount in words:

BANK ACCOUNT DETAILS

For direct payment of claims/ refunds in the account, please fill the following:

Bank Branch
MICR IFSC*
Account Number:
Account Type: Savings Current Cash Credit Overdraft
*Please enclose cancelled cheque along with the Proposal Form for direct payment in the account. In case the cheque doesn't bear a/c holder name or branch
IFSC code or both, kindly fill the NEFT mandate form

AUTO - RENEWAL OPTION

Do You wish to avail an auto-renewal facility (ECS payment) by way of which we will automatically renew your Policy for the period for which it has been issued
for. (Please tick Yes, if opted for) Yes No
I/we hereby declare and undertake that the amount paid by me/us as premium for the aforementioned policy is out of my/our lawful and declared source of income

Signature of the proposer/customer: Place: ______________________________ Date: D D / M M / Y Y Y Y

MEDICAL AND LIFESTYLE INFORMATION

Important: You must answer the following questions truthfully. Not doing so affects your coverage in case of a Claim.
SECTION A: Have any of the person proposed to be insured ever suffered from / are suffering from any of the following:
Please tick 'YES" for insured wherever applicable and provide details in Section B
Sr.No. Medical and Lifestyle Information Insured 1 Insured 2 Insured 3 Insured 4 Insured 5
1. Hypertension (High Blood pressure) History : Y N Y N Y N Y N Y N
a) Duration
b) Medications
c) Related Complications if any
d) Hospitalisation if any
Sr.No. Medical and Lifestyle Information Insured 1 Insured 2 Insured 3 Insured 4 Insured 5
2. Diabetes Mellitus (Sugar) History : Y N Y N Y N Y N Y N
a) Type I or Type 2
b) Duration
c) Medications - Insulin/ Tablets
d) Related Complications if any
e) Hospitalisation if any
3. Hyperlipidemia (Cholesterol) History: Y N Y N Y N Y N Y N
a) Duration
b) Medications
4 Does any person proposed to be insured smoke or consume
Tobacco in any form or alcohol. If yes, please indicate the quantity
consumed. If not please indicate No.
a) Smoking: Cigarettes/Bidi/Cigar Y N Y N Y N Y N Y N
1. Number of Cigarettes/Bidi/Cigar per day
2. Number of years
b) Tobacco in any form Y N Y N Y N Y N Y N
1. Amount per day
2. Number of years
c) Alcohol Y N Y N Y N Y N Y N
1. Number of Units per week
2. Number of years

Yes / No Insured No
5 Heart and Circulatory Conditions/Disorders: chest pain, angina, palpitations, congestive heart failure, coronary artery Y N 1 2 3 4 5
disease, heart attack, bypass surgery/angioplasty, valve disorder/replacement, pacemaker insertion, rheumatic fever,
congenital heart condition, varicose veins, clots in veins or arteries, blood disorders, anti-coagulant therapy etc.
6 Urinary Conditions/Disorders: Blood in urine, increase in urinary frequency, painful/difficult urination Kidney and/or Y N 1 2 3 4 5
Bladder infections, stones of urinary system, kidney failure, dialysis or Any Other Kidney/Urinary Tract Or Prostate
Disease
7 Musculoskeletal Conditions/Disorders: Joint/back pain Arthritis, Spondylosis,Spondylitis, SPinal disorders/Surgeries Y N 1 2 3 4 5
Osteoporosis, Osteomyelitis Joint Replacement Or Any Other Disorder of Muscle/ Bone/ Joint/ ligaments, tendons or
discs, gout, herniated disc, fractures/ accidents/ implants, amputation/prosthesis, Muscle weakness, Polio etc
8 Respiratory Conditions/Disorders: Shortness/difficulty of breath, Tuberculosis, Asthma, Bronchitis, Chronic Obstructive Y N 1 2 3 4 5
Pulmonary Disease COPD,chronic cough , coughing of blood, etc or any Other Lung / Respiratory Disease
9 Digestive Conditions/Disorders: Jaundice, chronic diarrhea, intestinal bleeding/problems/polyps, diseases of the Y N 1 2 3 4 5
pancreas, liver or gall bladder, hepatitis A/B/C/other, jaundice, Ulcerative colitis, Chron's disease, Inflammatory/ irritable
bowel disease, Cirrhosis, unexplained weight loss or gain, eating disorder or any Other Gastro Intestinal condition
10 Cancer/Tumor: Benign Or Malignant tumor, Any Growth/Cyst, any Cancer diagnosed earlier and/or treatment taken for cancer Y N 1 2 3 4 5

11 Brain/Nervous System/ Mental/Psychiatric Conditions/Developmental Disorders/Congenital/Birth defect: Loss of Y N 1 2 3 4 5

consciousness, fainting, dizziness, numbness/tingling, weakness, paralysis, head injury, stroke, migraine headaches or
chronic severe headaches, sleep apnea, multiple sclerosis, seizures/epilepsy or any Other Brain/ Nervous System Disease,
Mental/Psychiatric disorder, ADHD, autism, disability or deformity whether physical or mental,etc.
12 Female Reproductive Conditions/Disorders: Pelvic pain, abnormal, menstrual bleeding abnormal PAP smear, Y N 1 2 3 4 5
endometriosis, Fibroid, Cyst/ Fibroadenoma, Bleeding Disorder, Pelvic infection Or Any Other Gynecological / Breast
cysts/lumps/tumor
13 Eye, Ear, Nose and Throat Disorders: Cataract, glaucoma, Opticneuritis, retinal detachment, conjunctivitis, squint, ptosis, Y N 1 2 3 4 5
Blindness, refractive error/ spectacle number in dioptres; otitis media, Deviated Nasal Septum, Otosclerosis, Loss of speech,
Hearing loss, nasal polyps, chronic sinusitis Any other disorder of Ear, Nose and Throat
14 Sexually Transmitted Diseases: HIV/AIDS, immunodeficiency or any venereal disease (VD)/ sexually transmitted Y N 1 2 3 4 5
disease(STD)
15 Metabolic, Endocrine Conditions/Disorders and autoimmune/genetic disorder: Adrenal/pituitary disorders, thyroid Y N 1 2 3 4 5
disorder, lupus, scleroderma, thyroid disorders, Thallasemia, anemia, Hemophillia, Obesity and related surgeries, etc.
16 Is any female member pregnant, tested positive with a home pregnancy test, or ectopic pregnancy, infertility treatment Y N 1 2 3 4 5
17 Does the person proposed to be insured suffer from any chronic or long-term medical condition, or have any other Y N 1 2 3 4 5
disability, abnormality or recurrent illness or injury or unable to perform normal activities?
18 Has any member consulted with or received treatment from any doctor or other health care provider for any other condition Y N 1 2 3 4 5
or symptom(s)/undergone any hospitalization/illness/surgery/ currently taking medication(s) for any condition or medical
procedures (including diagnostic testing)
19 Does the individual have a family history of any disease (like Heart disease/ brain disease/ cancer/ organ failure/ Y N 1 2 3 4 5
autoimmune/ genetic disorder

*The above list of questions is subject to modification as per the requirement.

SECTION B: Name and details of Illness / Medicine / Test / Surgery / Date of Last
Doctor's Name Hospital Name & Phone No.
Diopter grade (for questions answered as yes in SECTION A above) Consultation
Insured 1 :
Insured 2 :
Insured 3 :
Insured 4 :
Insured 5 :
 IMPORTANT NOTES
1. The information that you give to us on this proposal form or in any supplementary Information form or documentation supplied by you or on your behalf will influence
our decision to offer insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have communicated to us. It is therefore
important that your answer are complete and accurate in all respect.
2. The question in this proposal are indicative rather then exhaustive. You must provide us with all information relevant to the risk to be insured, even if it is not the subject of a
question in this proposal. If you are in any doubt as to what information should be given, you should liaise with your insurance advisor/ company.
3. Acceptance of your proposal would be subject to receipt of complete medical reports(wherever applicable), medical underwriting and realization of full premium
amount by the company and the insurance coverage will commence from the date of underwriting by the company.
4. The list of exclusions/ inclusions and other policy details are indicative, for complete list and comprehensive details kindly refer policy wordings.
5. The Policy shall become voidable at the option of the Company, in the event of any untrue or incorrect statement, misrepresentation, non- description or non-disclosure of
material particulars in the Proposal Form/personal statement, declaration and connected documents, or any material fact* information has been withheld by beneficiary
or anyone acting on beneficiary's behalf to obtain insurance.
*A material fact will mean and include all important, essential and relevant information, pertaining to the questions made in this proposal form, that are likely to influence
company's acceptance or assessment of the proposal.

STATUTORY WARNING
PROHIBITION OF REBATES
(Under Section 41 of Insurance Act 1938)
1. 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
or renewing or continuing a policyaccept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to Ten lakh rupees.
DECLARATION
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.
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.
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/proposal after the proposal has been
submitted but before communication of the risk acceptance by the company.
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/proposed 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.
I/We declare to having no objection to receiving relevant information pertaining to my policy/claims/renewal/servicing on messaging platforms such as WhatsApp etc.
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 Government and /or Regulatory authority. I/We hereby declare that I/We are not politically exposed person as defined below.

Signature of the proposer/customer: Place: ____________________________ Date: D D / M M / Y Y Y Y

Declaration when the proposal form is filled by a person other than the proposer/ the proposer signs in a vernacular language/ proposer is illiterate
I hereby declare that I have read out and explained the content of this proposal form and all other connected documents incidental to availing the insurance policy from ICICI Lombard
GIC Ltd. to the proposer and that he/ she confirmed that he/ she has understood the same and that he/ she agrees to abide by all the terms & conditions of the same.
I hereby declare that I have fully explained to the proposer the answers to the questions that form the basis of the contract of insurance have also explained the contents in this
form to the proposer in _____________ language, that I have truly and correctly recorded the answers give by the proposer and that the proposer has affixed his/ her
thumb impression on the proposal form in my presence, after fully understanding the contents thereof. Further, this declaration does not confirm issuance of policy or
assumption of risk thereof.
I hereby state that the contents of the form and documents have been fully explained to me and that I have fully understood the significance of the proposed contract.
Name of Proposer: Name of Witness:

Signature of Proposer: Signature of Witness:

Date: D D / M M / Y Y Y Y Place:
Relationship with Proposer:
Address of Witness:

AGENT DECLARATION
full name
I,__________________________________________________________________________________in my capacity as an Insurance Advisor/ Specified Person of
the Corporate Agent/Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form, including the
nature of the questions contained in this Proposal Form to the Proposer 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 for issuance of the Policy. I have further
explained that if any untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits, statements, submissions,
furnished/to be furnished, the Company shall have the right to cancel the policy at its discretion. Further, this declaration does not confirm issuance of policy or assumption
of risk thereof.
Agent Name:__________________________________________________________
20210706012-AROGYA SANJEEVANI POLICY-FORMS

Signature : Place: _____________________________ Date: D D / M M / Y Y Y Y

SP Name : SP Code:
License No. (Advisor/Corporate Agent/Broker/Relationship Officer)

Mailing Address: ICICI Lombard General Insurance Company Limited, Interface Building No.11, 401/402 4th Floor, New Link Road Malad (W), Mumbai - 400064.
Registered Address: ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com • Mail us at [email protected]
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile) SMS Facility "HEALTHCLAIM" to 575758
ICICI Lombard General Insurance Company Limited. Insurance is the subject matter of the solicitation. IRDA Reg. No. 115. CIN: L67200MH2000PLC129408. Misc 171. URN: PF/4171/02.