Details of Proposer

Name
Gender
Marital Status
Date of Birth
E-mail id
Phone No.
Communication Address
Permanent Address
Nationality
Occupation
Aadhaar No.
Income Bracket
Family Size (no. of person taking the policy)
Plan
Sum Insured
Premium

Details Insured 1
Name
Gender
Date of Birth DD/MMM/YYYY
Height feet / inch
Weight Kg
Relationship with proposer
Does any person proposed to be insured
consumes alcohol,
smokes or other. If yes, please indicate the
name and quantity per week.
Is any of the Insured currently having Health
Insurance Policy (Please provide details)
PED* Yes/ No
Details of PED :
Inception Period
Treatment
Current Status

Additional detail from proposer :

Nominee Name
Nominee Relation
Nominee Date of birth

* PED means any condition for which the patient has already received medical advice or treatment prior to enrol
 Insured 2 Insured 3 Insured 4

DD/MMM/YYYY DD/MMM/YYYY DD/MMM/YYYY

feet / inch feet / inch feet / inch
Kg Kg Kg

Yes/ No Yes/ No Yes/ No

medical advice or treatment prior to enrollment in a new medical insurance plan

 Insured 5

DD/MMM/YYYY
feet / inch
Kg

Yes/ No