PROPOSAL FORM
POS PAN No. ((Mandatory for POS Agent): Intermediary Name :
Intermediary Code:
Proposal no:
This is an application for insurance and does not amount to acceptance of coverage by us. Commencement of risk under this proposal is subject
to we accepting it and receipt of full 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 cancellation
of policy.
Please ll-up this form in CAPITAL LETTERS
1. PROPOSER’S DETAILS
Name (Mr/Mrs/Ms/Dr):
First Name Middle Name Surname
Marital Status: Married
Single Others Gender : Male Female
Date of Birth:
D D M M Y Y Y Y
Occupation: Pvt Service Govt Service Business
Mobile:
Unique ID
PAN Card*:
OR Voter’s ID
E-Mail:
Income(in lakhs) Upto 3 3-6 6-10 10-15 15-20 20-25 >25
Address:
Landmark
Area
City/Town District
Pin Code State
2. OTHER DETAILS
Plan type: Floater Individual
Sum Insured: Rs.__________________________100,000 to 500,000 (in multiples of Rs. 50,000)
Premium payment mode:_____________( Yearly / Half yearly /Quarterly /Monthly)
3. DETAILS OF THE PERSON(S) TO BE INSURED
Sl
No.
Name of the
Insured Person
Gender
M / F
Relationship
with Proposer*
Date of Birth
D|D|M|M|YYYY
Unique ID
Height
cms
Weight
kgs
Sum
Insured
#
1
2
3
4
5
6
7
8
* Allowed relations (Spouse, children and Parent and Parent in law) # Same Sum Insured for all members in oater option
Regd Oce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
IRDA of India Registration No: 108 Website: www.tataaig.com CIN: U85110MH2000PLC128425 | UIN: TATHLIP20169V011920
AROGYA SANJEEVANI POLICY,
TATA AIG GENERAL INSURANCE COMPANY LTD.
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. The nominee must be an immediate relative of the Proposer. The nominee for all other Insured Persons proposed to
be insured shall be the Proposer himself/ herself.
Nominee Name Date of birth* Relationship
*If the Nominee is minor, Name and relationship with Minor:
Appointee Name Relationship
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
* In case of portability, please ll up IRDAI portability form. Please note that continuity of benets shall NOT be considered if the details are
not provided. You need to approach at least 45 days prior to your expiry date to avoid any break in coverage. Please submit all previous year
insurance policy copies.
6. MEDICAL AND LIFESTYLE DETAILS
Policy No.
Name of
Insured person
Insurer
Period of Insurance
SI &
Cumulative
bonus / Rs.
Claims lodged
during the preceding
years along with the
diagnosis
From
D|D|M|M|YYYY
To
D|D|M|M|YYYY
*during the preceding years along with the diagnosis
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 by ticking the relevant box.
Insured Person
1 2 3 4 5 6 7 8
Have you or any of the persons proposed for insurance, ever suered from or taken treatment, or hospitalized for or have been recommended
to take investigations / medication / surgery or undergone a surgery for the following medical conditions?
Chest Pain / Heart Disease
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Arthritis
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
COPD
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Kidney Failure, Dialysis
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Liver Cirrhosis/Hepatitis B or C
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Cancer
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Stroke, Epilepsy, Paralysis
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Ulcerative Colitis/Crohn’s disease
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Auto-immune diseases
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Any other illness/disease/injury/disability in the past other than for
childbirth, u or for minor injuries that have completely healed?
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Are you or any persons proposed on regular medication (including any
Ayurvedic treatment) or awaiting any procedure/treatment?
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Application no:
Regd Oce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
IRDA of India Registration No: 108 Website: www.tataaig.com CIN: U85110MH2000PLC128425 | UIN: TATHLIP20169V011920
2
AROGYA SANJEEVANI POLICY,
TATA AIG GENERAL INSURANCE COMPANY LTD.
Have you ever been diagnosed with any of these medical conditions with
or without any follow-up tests/medications? –
Elevated Blood Sugar /
Diabetes / Elevated Blood Pressure / Hypertension /
High Cholesterol / Hypothyroidism
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Has any application for life, Health or critical illness insurance ever
been declined, postponed, loaded or been made subject to any special
conditions by any insurance company?
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Has any health or life insurance policy ever been terminated in the past?
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Is any of the insured pregnant currently? If yes, please mention expected
date of delivery (EDD). Any history of pregnancy related complications?
Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
EDD:
D D M M Y Y Y 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.)
Insured Name
Diagnosis as per
documents
Treatment details
Diagnosis date/
Surgery Date
Date of last
consultation
Doctor/Hospital
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.
Insured Person
1 2 3 4 5 6 7 8
Alcohol (equivalent of 30ml Pegs of hard liquor/ bottles of beer/wine)
Per day / Per week / Per month / Occasionally
Smoking (No of Cigarettes or Bidis)
Per day / Per week / Per month / Occasionally
Pan Masala/Tobacco (no. of small -5gms-Packets)
Per day / Per week / Per month / Occasionally
Others habit forming substances/addictive (Quantity consumed)
Per day / Per week / Per month / Occasionally
7. PAYMENT DETAILS
Name of the Premium Payer:
if dierent from proposer
Relationship with the proposer:
if dierent from proposer
Premium Amount (Rs):
Instrument type: Cash Cheque Debit Card Credit Card Others
Please make a Crossed Cheque/DD/Pay Order in favour of ‘Tata AIG General Insurance Company Limited’ only.
Sources of funds: Salary
Business Other
AML guidelines:
1. I/we hereby conrm that all premiums have been/will be paid from bonade sources and no premiums have been/will be paid out of
proceeds of crime related to any of the oence listed in Prevention of Money Laundering Act, 2002.
2. I understand that the Company has the right to call for documents to establish sources of funds.
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 law in India.
Nationality : Indian Non-Indian If Non-Indian, please specify Country
Application no:
Regd Oce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
IRDA of India Registration No: 108 Website: www.tataaig.com CIN: U85110MH2000PLC128425 | UIN: TATHLIP20169V011920
3
AROGYA SANJEEVANI POLICY,
TATA AIG GENERAL INSURANCE COMPANY LTD.
Type of Organization making the payment (Pls tick)
Limited company Government organization Non-Governmental Organization (NGO) Society
Trust Partnership International Organization Cooperatives Section 25 Company
Signature of Proposer: Date:
8. BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)
As per Regulatory requirements, we can eect payment of refund/claims only through Electronic Clearing System (ECS) / National Electronics 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)
If the premium cheque is not paid from the above mentioned account then a cancelled cheque leaf of the above mentioned Account is to be
attached. #mandatory if annualized premium is more than Rs 10,000
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 particulars given
by me are true and complete in all respects to the best of my knowledge and that I am 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 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 on the
person to be insured/proposer or from any past or present employer concerning anything which aects the physical or mental 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.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole
purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
Signature of Proposer:
Date:
GoGreen: I would like to protect my environment and would like to help save paper by authorizing Tata AIG General Insurance Company Limited
to send all my policy and service related communication to the email id as mentioned in this proposal form.
10. DECLARATION/VERNACULAR DECLARATION
The content of this form along with product benets, terms/conditions and exclusions have been clearly explained to me. I/we have understood
these and conrm to abide by the policy terms & conditions.
Signature of Proposer: Code:
Name & Signature of agent/intermediary:
Vernacular Declaration (Certication in case the proposer has signed in vernacular/thumb print)
The content of this form along with product benets, terms/conditions and exclusions have been clearly explained by me in vernacular to the
proposer who has understood and conrmed the same.
Signature/Thumb impression of the Proposer
Name & Signature of agent/intermediary
11. AGENT DECLARATION
I, (Full Name) in my capacity as an
Insurance Advisor/ Specied Person of the Corporate Agent/Authorized employee of the Broker/Relationship Ocer, 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), adavits, statements, submissions, furnished/to be furnished, the Company shall have the right to vary the benets which
may be payable and further more if there has been a non-disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal
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
Agent/Broker/Relationship Ocer)
Name of the specied Person and code:
Signature of Agent: Place: Date:
12. Prohibition of Rebates - Section 41 of Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
1. No person shall allow or oer 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 policy accept 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.
13. FOR OFFICE USE ONLY
Tata AIG Oce Code: 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:
Regd Oce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
IRDA of India Registration No: 108 Website: www.tataaig.com CIN: U85110MH2000PLC128425 | UIN: TATHLIP20169V011920
AROGYA SANJEEVANI POLICY,
TATA AIG GENERAL INSURANCE COMPANY LTD.
ACKNOWLEDGEMENT
Name of the Proposer:
We acknowledge with thanks the receipt of your proposal for Arogya Sanjeevani Policy, Tata AIG General Insurance Company Ltd. 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 proposal obliges us to agree to issue a policy, this 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 have
no liability to make any payment if proposal is not accepted by us or you do not accept the terms of counter oer or premium is not received by us in full and in
time, or non-fulllments of Pre-Policy Checkup and/or additional information requested by us. We shall have no liability to make any payment under the Policy if
proposal is under-process & claim arises in the interim period before the decision on the proposal is given by us. In case of counter oer you need to revert to Us
with consent and additional premium (if any), within 30 days of the issuance of such counter oer letter. In case, You neither accept the counter oer nor revert to
Us within 30 days, we shall cancel proposal and refund the premium paid without interest subject to deduction of the Pre Policy Check up charges, as applicable.
If we do not accept the proposal, we will inform you and refund any payment received from you without interest within next 10 days subject to deduction of the
Pre-Policy Check up charges, as applicable.
Proposal no:
Date :
Tata AIG General Insurance Company Limited.
Regd Oce: 15th Floor, Tower A, Peninsula Business Park, G. K. Marg, Lower Parel, Mumbai - 400 013
Toll Free No. (24x7): 1800 266 7780 OR 1800 229966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
IRDA of India Registration No: 108 Website: www.tataaig.com CIN: U85110MH2000PLC128425 | UIN: TATHLIP20169V011920
AROGYA SANJEEVANI POLICY,
TATA AIG GENERAL INSURANCE COMPANY LTD.