Proposal Form No.

: 3250509689 ManipalCigna Health Insurance Company Limited

(Formerly known as CignaTTK Health Insurance Company Limited)
Corporate Office: 401/402, Raheja Titanium, Western Express Highway,
Goregaon (E), Mumbai - 400063. IRDAI Registration No. 151.
Call (Toll Free): 1800-102-4462 Visit: www.manipalcigna.com
E-mail: [email protected] CIN No.: U66000MH2012PLC227948

I. PROPOSER DETAILS:

Title* : Mr. Mrs. M/S Ms. Gender* : Male Female Others

Date of Birth* : 15/03/1982 Martial Status* : Married Unmarried Others

Name* (as in bank account) : AMJUDUNNISA SHAIK

Permanent Address*: (as in bank account) : 27 1 43 MASEED CENTER BALAJI NAGAR

Landmark* :

City : Nellore Town (District) : NELLORE

State* : Andhra Pradesh Pin Code* : 524002

Correspondence Address* : 27 1 43 MASEED CENTER BALAJI NAGAR

Landmark* :

City : Nellore Town (District) : NELLORE

State* : Andhra Pradesh Pin Code* : 524002

Email Address^^ : Address 2

Address 1 [email protected]

Telephone Number(s): Mobile^^: 9347874960 Residence (Optional):

Residence (Optional):

Would You like to subscribe to important alert on Whatsapp? Yes No

Policyholders have the option to access their Policy documents through DigiLocker with no additional charges.
To learn more about DigiLocker, please visit https://www.manipalcigna.com/video/
Would you prefer to receive all policy document digitally (via email/soft copy)?
Yes (I would like to receive policy document digitally). No (I prefer to receive policy document in hard copy).

Occupation : Government Service Private Service Self Employed Others

This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.
 Annual Income : Up to ₹ 50,000 ₹ 50,000 to ₹ 5 Lacs ₹ 5 to 10 Lacs ₹ 10 to 15 Lacs
₹ 15 to 20 Lacs Above ₹ 20 Lacs

Educational Qualificatin: :Less than class X Class X Class XII Graduate Post Graduate Professional Degree

Customer Goods & Service Tax identification Number (if any)* :

Nationality: Indian NRI Others (Please specify):

PAN Card Number LJHPS1685L(mandatory for premium of ₹ 50,000 and above accepeted in Cash/DD or ₹ 10,000 by Credit/Debit Card

Form 60* (only in case where PAN number is not available) : YES No Aadhar Number/ VID Number:

Family Physician Details

Name :

Contact number :

Email id :

Address

Do you wish to assign a Caregiver for your policy/ies? YES No If Yes, please provide:

Name :

Mobile number :

Relationship with Proposer :

Age(in Years) :

Email id :

Caregiver can be close family member who would take care of the insured person in any kind of health care event,whether emergency or planned.The Caregiver might not be SOS contact.

^^Please provide the details to enable us to serve you better.

-->

II. NOMINEE DETAILS:

Is the Nominee same as Caregiver (if provided above)? YES No If No, please provide Nominee details.

Nominee Name : SHAIK FASEEHA

This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.

Relationship with Proposer: Daughter

 Nominee Age : 26

In the event of death of the Proposer, any payment due under the Policy shall become payable to the nominee, as per section 39 of the Insurance Act, 1938, as amended from time to time and the
receipt of the proceeds by such nominee would be sufficient discharge to the Company. For all other persons covered under the Policy, the Proposer will be the nominee.

Appointee details: (Required only if nominee is a minor)

Appointee Name:

Relationship with Nominee:

Age :

A#A Minor should not be declared as Appointee.

III. POLICY/PLAN DETAILS*:

Tenure: 1 Year 2 Year 3 Year

Proposed Policy Period: From :

(Must be on or later than instrument date/ premium payment date)

Insured Details*: (Deductible and Sum Insured only for individual cover)

Sr. Name Gender* DOB* Relationship Height* Weight* Occupation/ Industry Type City*
No. (First* Middle Last*) (M/F/O) (DD/MM/YYYY) with Proposer* (Cms) (kgs)

1 AMJUDUNNISA SHAIK Female 15/03/1982 Self 160 55 Self Employed Nellore

2
3
4
5
6
7
8

V. INSURED OTHER DETAILS*:

Sr. Name ABHA Maternity & New Born CKYC PEP(Y/N) Nature Of Nature Of Job Personal Accident Temporary Total
No. Number Hospitalization Expenses Number Job Others Cover Disablement

1 AMJUDUNNISA NO No
SHAIK
2
3
4
5
6
7
8
All insured Indian national and Indian residents? Yes No
MANIPALCIGNA SARVAH - PARAM [UIN: MCIHLIP25035V012425]
Plan Type* : Individual Floater Portability: Yes No Migration: Yes No
(If yes portability form to be (If yes migration form to be completed and attached)
completed and attached)

5 Lacs 10 Lacs

3.5 Lacs 15 Lacs

4.5 Lacs 20 Lacs
Sum Insured
5.5 Lacs 25 Lacs
7.5 Lacs 30 Lacs
50 Lacs 100 Lacs
200 Lacs 300 Lacs

1. Deductible

Option – 1: Aggregate Deductible*:

10,000 25,000 50,000 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 10,00,000

Option – 2: Daily Deductible

1,000/day 2,000/day 3,000/day 4,000/day 5,000/day

2. Air Ambulance
3. Room Rent Modification
ANYROOM
SHAREDROOM

4. Surplus Benefit
5. Voluntary Co-Payment
10%
20%
30%

6. Sarathi (only for Pratham and Uttam)

7. Gullak (Guaranteed 100% increase in Sum Insured per year, maximum up to 1,000% irrespective of claim under the Policy and only for Pratham and Uttam)

8. Restoration of Sum Insured (only for Pratham and Uttam)

9. Accidental Hospitalization (only for Pratham)

10. Coverage for Non-Medical Items and Durable Medical Equipment’s

11. Health Check-up (only for Pratham and Uttam)

12. Anant (only for Uttam)

13. Pratiksha (only for Param)

Note:
Personal Accident Cover: The minimum entry age under this policy is 5 years and maximum age at entry is 65 years. In case of Family Option – Sum Insured for non-earning spouse/live
in partner will be limited to 60% of the Proposer and for Dependents (Children/Parents/In-laws) will be limited to 30% of the Proposer, subject to maximum Rs. 30 Lacs
 TTD Cover: Available only for earning member. This will be available if Personal Accident Cover is opted.
Optional Cover – ‘Sarathi’ is available only during the first Policy Year and not available during renewal. Once opted cannot be opted out in the subsequent renewals.
Voluntary Co-payment and Deductible cannot be opted at same time.
This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage.

VI. MEDICAL AND LIFESTYLE INFORMATION*:

Medical questions Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8
Has any of the applicants ever been diagnosed with or
suspected to have Cancer or Rheumatoid Arthritis or Ulcerative
Colitis or Crohn's disease or Chronic Liver Disease, Hepatitis
B, Cirrhosis or Chronic Kidney Disease or Kidney failure or
Epilepsy or Fits or Stroke or Paralysis or Parkinsonism or YES YES YES YES YES YES YES YES
Q1
Alzheimer's or Multiple sclerosis or Brain Tumor or Cerebral NO NO NO NO NO NO NO NO
Palsy or Heart Failure or Heart Attack or Angina or Coronary
Artery Disease or Ischemic Heart Disease or Chronic Bronchitis
or Intestitial Lung Diseases or Pneumoconiosis or Emphysema.
(If Yes, tick against the disease)
Cancer YES YES YES YES YES YES YES YES
i
NO NO NO NO NO NO NO NO
Rheumatoid Arthritis / Ulcerative Colitis / Crohn's disease YES YES YES YES YES YES YES YES
ii
NO NO NO NO NO NO NO NO
Chronic Liver Disease, Hepatitis B, Cirrhosis YES YES YES YES YES YES YES YES
iii
NO NO NO NO NO NO NO NO
Chronic Kidney Disease / Kidney failure YES YES YES YES YES YES YES YES
iv
NO NO NO NO NO NO NO NO
Diseases of the Brain -
YES YES YES YES YES YES YES YES
v Epilepsy/Fits/Stroke/Paralysis/Parkinsonism
/Alzheimer's/Multiple sclerosis/Brain Tumor/ Cerebral Palsy NO NO NO NO NO NO NO NO

Diseases of Heart - Heart Failure/Heart

YES YES YES YES YES YES YES YES
vi Attack/Angina/Coronary Artery Disease/Ischemic Heart
Disease NO NO NO NO NO NO NO NO

Chronic diseases of the Lungs - Chronic Bronchitis/ Intestitial YES YES YES YES YES YES YES YES
vii Lung Diseases/ Pneumoconiosis/ Emphysema NO NO NO NO NO NO NO NO
Has any member ever suffered or currently suffering from or
under treatment (operated, hospitalised, investigated) or been YES YES YES YES YES YES YES YES
Q2
under medication for more than a week for any medical NO NO NO NO NO NO NO NO
condition.
Diabetes Mellitus YES YES YES YES YES YES YES YES
i
NO NO NO NO NO NO NO NO
This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage.

1 How does the applicant manage his/her diabetes / pre-diabetes?

a Insulin
b Oral diabetic medication
c No medicine
 d Any other treatment
How many medicines does the applicant take to manage his/her
2
diabetes / pre-diabetes?
a No medicine
b One medicine
c Two medicines
d Three or more medicines
How long ago was the applicant first diagnosed with diabetes /
3
prediabetes
a 1 - 5 years
b 5 - 10 Years
c 10 - 15 years
d More than 15 Years
b)Type of Diabetes Type 1 Type 1 Type 1 Type 1 Type 1 Type 1 Type 1 Type 1
ii
Type 2 Type 2 Type 2 Type 2 Type 2 Type 2 Type 2 Type 2
c. Latest HbA1c (within 90 days)
d. d) Fasting Blood sugar value (within 90 days)
Hypertensionl YES YES YES YES YES YES YES YES
ii
NO NO NO NO NO NO NO NO
How does the applicant manage his/her Hypertension / High
1
Blood Pressure?
a No medicined
b One medicine
c Two medicines
d Three or more medicines
When was the applicant first diagnosed with Hypertension /
2
High Blood Pressure?
a 1 - 5 years
b 5 - 10 Years
c 10 - 15 years
d More than 15 Years
a) Latest Systolic Blood Pressure reading (within 90 days)
b) Latest Diastolic Blood Pressure reading (within 90 days)
High Cholesterol YES YES YES YES YES YES YES YES
iii
NO NO NO NO NO NO NO NO

This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage.
 Is any of the applicant under medication for high cholesterol /
1
high triglycerides
a Yes
b No
a) Latest Total Cholesterol value (within 90 days)
b) Latest LDL value (within 90 days)
c) Latest Triglycerides value (within 90 days)
Thyroid disorders YES YES YES YES YES YES YES YES
iv
NO NO NO NO NO NO NO NO
1 Which thyroid disorder is the applicant suffering from?
a Goitre
b Hyperthyroidism (high thyroid activity)
b Hypothyroidism (low thyroid activity)
d Other thyroid disorders
e Thyroid Nodule
f Thyroditis
g Any other
Heart and Lung disorders YES YES YES YES YES YES YES YES
iv
NO NO NO NO NO NO NO NO
1 Asthma
2 Tuberculosis
3 Upper Respiratory Tract Infection
4 Lower Respiratory Tract Infection
5 Varicose veins
6 DVT (Deep vein thrombosis)
7 Syncope
8 Hypotension (Low Blood Pressure)
9 Varicocele
10 Lung Abscess
11 Allergic Bronchitis
12 Any other heart and lung condition
Digestive system disorders (Stomach and related organs) YES YES YES YES YES YES YES YES
vi
NO NO NO NO NO NO NO NO
1 Peptic ulcer (Ulcer in stomach or duodenum)
2 Appendicitis
3 Cholecystitis/Cholelithiasis (Gall Bladder stones)
This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage
 4 Hemorrhoids(Piles)
5 Anal Fissure)
6 Anal Fistula
7 Pancreatitis
8 Umbilical Hernia (Hernia at navel)
9 Inguinal Hernia (Hernia in groin)
10 Irritable bowel syndrome
11 Fatty liver
12 Any other
Brain, nerve and Psychiatric (Mental) disorders YES YES YES YES YES YES YES YES
vii
NO NO NO NO NO NO NO NO
1 Recurring or severe headaches / Migraine
2 Febrile Convulsions
3 Vertigo (Recurrent dizziness))
4 Encephalitis
5 Mental Retardation
6 Anxiety
7 Depression
8 Psychosis
9 Any other psychological disorders
10 Dementia (Memory loss)
11 Attention deficit Disorder
12 Any other
Other Endocrine (Hormonal) disorders YES YES YES YES YES YES YES YES
viii
NO NO NO NO NO NO NO NO
1 Parathyroid gland disorders
2 Adrenal Disorder
3 Pituitary Disorders
Bone, joints and muscle disorders YES YES YES YES YES YES YES YES
ix
NO NO NO NO NO NO NO NO
1 Gout / Hyperuricemia (high uric acid in blood)
2 Osteoarthiritis
1. Diagnosed OA in Knee/Hip
2 Knee/Hip: Right/Left/Both Knee/Hip
Surgery/Knee or Hip replacement: Not done/ Right/Left/Both
3
knee/Hip
If Not diagnosed with Osteoarthritis, are you suffering from Yes Yes Yes Yes Yes Yes Yes Yes
b) knee/Hip/ Ankle/Hand fingers joint pain which restricts your No No No No No No No No
 daily physical activities or requires you to take pain killers.
3 Shoulder Dislocation
This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage.

4 Spondylitis / Spondylosis
5 Osteoporosis
6 Prolapse of Inter-vertebral disc (disc prolapse)
7 Total Knee Replacement
8 Total Hip Replacement
9 Any other
Ear, nose, eye and throat disorders YES YES YES YES YES YES YES YES
x
NO NO NO NO NO NO NO NO
1 Otitis-media (middle ear infection)
2 Hearing loss
3 Nasal Polyp
4 Sinusitis
5 Deviated Nasal Septum
6 Tonsillitis
7 Pharyngitis (throat infection)
8 Cataract
In Which Eye Right Right Right Right Right Right Right Right
Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
Left Left Left Left Left Left Left Left
1 Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
Both Both Both Both Both Both Both Both
Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
Cataract Surgery Right Right Right Right Right Right Right Right
Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Left Left Left Left Left Left Left Left
Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
2 Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Both Both Both Both Both Both Both Both
Eye Eye Eye Eye Eye Eye Eye Eye
Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery

Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery

Not Done Not Done Not Done Not Done Not Done Not Done Not Done Not Done
b) b) If not diagnosed with Cataract are you suffering from Yes Yes Yes Yes Yes Yes Yes Yes
 Dimness/ Blurring of vision No No No No No No No No
9 Glaucoma
10 Vocal Cord Nodule
11 Any other
Genito-urinary and Gynaecological disorders YES YES YES YES YES YES YES YES
xi
NO NO NO NO NO NO NO NO
1 Kidney / bladder stones
2 Recurrent Urinary tract infection
3 Stricture Urethra
4 Cytitis/ Infection of urinary bladder
5 Urinary incontinence
6 Benign Hypertrophy of Prostate
7 Hydrocele
8 Torsion of testes
9 Phimosis
10 Breast lump / Cyst / abscess
11 Ovarian cyst

This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage.

12 Endometriosis
13 Fibroid Uterus
14 Menstrual disorder / irregular or excessive bleeding
15 Bartholin's abscess / cyst
16 Vaginal prolapse
17 Cervical polyp
18 Any other
Blood and related disorders YES YES YES YES YES YES YES YES
xii
NO NO NO NO NO NO NO NO
1 Anaemia
2 Thalassaemia
3 Sexually transmitted diseases
4 HIV / AIDS (Acquired Immuno-deficiency syndrome)
Skin disorderss YES YES YES YES YES YES YES YES
xiii
NO NO NO NO NO NO NO NO
1 Psoriasis
2 Eczema
 3 Dermatitis
4 Urticariar
5 Vitiligo
6 Cyst/ lump/ growth / polyp / tumour
7 Any other
Any other condition / illness / disorder / surgery YES YES YES YES YES YES YES YES
xiv
NO NO NO NO NO NO NO NO
Have you underwent any surgery in past: If Yes, please share Yes Yes Yes Yes Yes Yes Yes Yes
a) the below details No No No No No No No No
1) Name of Surgery
2 Location
Any history of accidents in past: If Yes, please share the below Yes Yes Yes Yes Yes Yes Yes Yes
b) details No No No No No No No No
1 1. Exact site & details of injury
Any Implant used Yes Yes Yes Yes Yes Yes Yes Yes
2.
No No No No No No No No
Has any of the applicants recommended to undergo or has
undergone any pathologic or radiologic tests for any illness YES YES YES YES YES YES YES YES
Q3
other than the ones listed above and routine or annual health NO NO NO NO NO NO NO NO
check-up?
Has any of the applicants recommended to undergo or has
undergone any pathologic or radiologic tests for any illness YES YES YES YES YES YES YES YES
Q4
other than the ones listed above and routine or annual health NO NO NO NO NO NO NO NO
check-up?
Habits and Lifestyle questions Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8
Does any of the insured/s chew tobacco / smoke / consume YES YES YES YES YES YES YES YES
Q5 alcohol? Please tick the relevant box(es) below NO NO NO NO NO NO NO NO
Smoke YES YES YES YES YES YES YES YES
A
NO NO NO NO NO NO NO NO
This form is verified by way of a One Time Password(OTP) send to mobile number ******4960 The details provided in this proposal include the information provided at the Quote Stage

VII. ADDITIONAL MEDICAL INFORMATION:

If answers to Q2 are 'Yes', please provide further details below. Please attach extra sheets if required.

1 Since how long does the applicant smoke

a <=20 years
b >20 years
Tobacco YES YES YES YES YES YES YES YES
B
NO NO NO NO NO NO NO NO
How many Pan masala / gutka packets does the applicant has in
1
a day
 a 1-3 packets/day
b 4-6 packets/day
c >6 packets/day
Alcohol YES YES YES YES YES YES YES YES
C
NO NO NO NO NO NO NO NO
1 How frequently does the applicant consume alcohol
a 1-3 days/ week
b 3-6 days / week
c Daily
For Lifestyle Protection – Accident Care & Accidental Death/PTD Add On
Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8
Cover
Has any of the applicants suffered or currently suffering from
seizure disorder or any physical or mental defects/ impairment/ YES YES YES YES YES YES YES YES
Q6
infirmity/ deformity or any condition that may effect mobility/ NO NO NO NO NO NO NO NO
sight/ hearing/speech
Does the applicant's occupation require him/her to engage in
manual labour or hazardous activities or handling hazardous YES YES YES YES YES YES YES YES
Q7
material or working at heights, as cabin crew, in sea/river faring NO NO NO NO NO NO NO NO
vessels, with high voltage, or be a part of armed forces?

This form is verified by way of a One Time Password (OTP) sent to the mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.

VII. CURRENT INSURANCE DETAILS :

In the unfortunate event of claim, the below information will facilitate Us, in case you have chosen Us as a Primary insurer to coordinate with other insurers to ensure the hassle free settlement of
your claim as per the applicable policy terms and conditions. in case you have chosen Us as a Primary insurer
Please fill the following details with respect to health indemnity insurance policies(s) currently with any other insurance company?

Sr.No. Policy No Insured Insurer Name From Date To Date Sum Insured Cumulative Bonus Earned

% Amount
1
2
3
4
5
6
7
8
For active polcies, please attach policy copies.
Insured wise information required with all the above information in 'Current Insurance Details'.

This form is verified by way of a One Time Password (OTP) sent to the mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.
 VIII. PAYMENT DETAILS*:

Premium Paid by : Relationship to Proposer : Self

Premium Amount : in Words :

Signature :

Payment Option: Credit Card Debit Card Net Banking Wallets UPI DIRECT DEBIT Cheque

^For Cash Payments of ₹ 50,000 and above PAN Number is Mandatory

For Cheque / DD / Credit Card/ Debit Card/ PO/ Others (Please specify) Credit Card For Cheque / DD / Credit Card/ Debit Card/ PO/ Others (Please specify)

Proposal form No : 3250509689

Instrument / Transaction Number : Instrument/Transaction Date :
Instrument /Transaction Amount :
Bank Name :

Payment to be collected only from Proposers Card/Bank

Account

IX. BANK ACCOUNT DETAILS*:

Mandatory details required to process all payment due in relation to your policy including refunds (if any) and / or claims directly to your bank account.
Please select any one of the below options as applicable.
Bank details as per premium cheque to be used for electronic fund transfer.
Bank account details as mentioned on the cheque being submitted along with the Proposal Form towards premium payment for insurance Policy should be used by the Company for
electronic fund transfer as mode of payment.
Please fill the below table if the premium payment cheque does not have all the details required for electronic fund transfer

This form is verified by way of a One Time Password (OTP) sent to the mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.

Particulars of Bank Account*:

Account Number: 018910100007587 IFSC / MICR Code: UBIN0801895
Name of the Bank: Union Bank of India Account Holder Name: SHAIK ANJUDDUNNISA

I agree and undertake to intimate in writing to ManipalCigna Health Insurance Co. Ltd about any change in bank account details. I also hereby certify that the
particulars furnished above are correct to the best of my knowledge.
DISCLAIMER: ManipalCigna shall not be liable to anybody, in any manner, whatsoever if the NEFT transaction does not complete for any reason whatsoever including without limitation- failure
on part of the Bank/s involved to perform any of their obligations for aforesaid NEFT transaction or incomplete/incorrect information by Customer/Policy Holder
Aforesaid NEFT transaction shall be governed by applicable Reserve Bank of India rules, directions & guidelines and shall be subject to participating Bank user terms and conditions related to NEFT
facility. ManipalCigna shall be indemnified against any loss/damage/claims caused to ManipalCigna in carrying out your aforesaid NEFT instructions.

Instructions:
 • It is important for these electronic payment systems that the Policy Holder's name in the Policy must exactly match with the name in the Bank Account records/details given above.
• In cases where beneficiary's bank account number & name is printed on the cheque, bank attestation is not required. For all other cases bank attested NEFT mandate is required.
• The customer who is willing to transfer the funds will be required to provide the 11 digits valid IFS Code, which is applicable for NEFT only. (a number allotted to each participating banks
branch) of the branch where the funds need to be transferred.
• Cancelled cheque should be attached along with the NEFT format.
• In case cancelled blank cheque does not bear account holder's name, please provide photocopy of bank statement / passbook with latest entries updated or else Bank attestation is required
• NEFT Form needs to be complete in all respect

Date:

X. DECLARATION & AUTHORISATION*:

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 authorised to propose on behalf of these other persons
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/proposer 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 anytime 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.
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 including seeking and/or sharing of my medical data through ABHA.
I consent to and authorize Company and its representatives to collect, use, share and disclose information provided by me, as per the privacy policy of the Company. Company or its representatives
are also hereby authorized to contact me (including overriding my registry on NCPR/NDNC and/or under any extant TRAI regulations) and / or notify about the services being rendered by the
Company”. Further, I hereby provide my consent and authorize Company and its representatives to collect the premium upfront at proposal stage. I hereby further declare that I am also aware of the
recent regulatory changes (details available at https://irdai.gov.in/web/guest/document-detail?documentId=5625747) , wherein Insurer has been asked to collect premium after acceptance of
proposal, however it would be difficult for me to subsequently submit premium at later stage to the insurer and hence I hereby request and authorize Insurer to accept my premium along with this
proposal, to avoid any inconvenience to me, at my sole cost and consequences.
I hereby agree to the Terms and Conditions of the policy/ies.
Date: Place: Nellore

This form is verified by way of a One Time Password (OTP) sent to the mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.

Section 41 of Insurance Act 1938 (Prohibition of rebates)::

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 premium shown on the policy, nor shall any person taking out or renewing or continuing a policy
accept any rebate, except such rebate as may be allowed in accordance with the prospectus or tables of the insurers.
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.

ACKNOWLEDGEMENT:

Received from Ms / Mrs / M: a sum of ₹

through Cash#/Cheque/DD/Credit Card/Debit Card No. against your proposal for XXX Policy.

Signature of ManipalCigna official / Intermediary: Date:

Date: Place
This form is verified by way of a One Time Password (OTP) sent to the mobile number ******4960 The details provided in this proposal include the information provided at the Quote stage.
Note:Neither the submission of a completed proposal for insurance or any payment for any Policy sought oblige the Company to agree to issue a Policy, which decision is and always shall be in the
Company's sole and absolute discretion
If ManipalCigna Health Insurance Company Limited accepts a proposal for insurance, it shall be subject to the board approved underwriting policy of the Company and the Policy terms and
conditions of the product and the Company shall have no liability to make any payment if premium is not received by ManipalCigna Health Insurance Company Limited in full and in time, or is not
realised.
Aforesaid NEFT transaction shall be governed by applicable Reserve Bank of India rules, directions & guidelines and shall be subject to participating Bank user terms and conditions related to NEFT
facility. ManipalCigna shall be indemnified against any loss/damage/claims caused to ManipalCigna in carrying out your aforesaid NEFT instructions.
Should you choose to pay premium by Cash, you are advised to do so only at the nearest ManipalCigna branch or its authorised collection points. Handing over cash to any Advisor/ Employee is
solely at your own risk and the Company shall in no way be held responsible for any loss in this regard.
If a proposal is not accepted, ManipalCigna Health Insurance Company Limited will inform you and refund any payment received from you without interest.
Insurance is a subject matter of solicitation