Proposal Form No.

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Peg rs o n a l & C a r i
n
Health Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Insurance
The Health Insurance Specialist
Chennai - 600 034.  Phone : 044 - 28288800  Email : support@[Link]
Website : [Link]  CIN : U66010TN2005PLC056649  IRDAI Regn. No. : 129
The company will not be on risk until the proposal has been accepted and
COMMON PROPOSAL FORM Ref. No. full payment of premium has been received.
Please fill up the form in block letters. Also submit photographs of each of the
Unique Reference No.: SHAI/PR0002 Policy No. person proposed for insurance for issuance of identity cards
Policy Issuing Office : SM
SM CODE
NAME
AGENT AGENT
CODE NAME
SPECIFIED SPECIFIED
PERSON PERSON
CODE NAME
Social Sector Classification* :  Yes  No If Yes :  a. Unorganised Sector  b. Other Categories of Persons
BUSINESS
TYPE

 c. Economically Vulnerable or Backward Classes  d. Informal Sector

Rural Sector Classification (This classification is based upon the address of the proposer) :  Urban  Rural
* “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural and urban areas.
a. “Unorganised sector” includes self-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers, fishermen, hamals, handicraft artisans, handloom and khadi workers, lady tailors,
leather and tannery workers, papad makers, powerloom workers, physically handicapped self-employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane cutters, tendu leaf collectors, toddy
tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and coolies or such other categories of persons;.
b. “Economically Vulnerable or Backward Classes” means persons who live below the poverty line;
c. “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 and who may not be gainfully employed; and also includes guardians
who need insurance to protect spastic persons or persons with disability;
d. “Informal Sector” includes small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of generating employment and income, with heterogeneous activities like retail trade, transport, repair and
maintenance, construction, personal and domestic services and manufacturing, with the work mostly labour intensive, having often unwritten and informal employer-employee relationship;

Name of the Proposer

Mr / Mrs / Ms. Date of Birth :
Occupation of the
Proposer Annual Income Rs.:
Residence Address

Office Address
Healt h P in Code :

Pe rs o n a l & C a r i Insurance
ng
The Health Insurance SpecialistPin Code :
Email ID : Mobile Number
Period of
Aadhar (UID) Number To
Insurance

GST Number PAN Number

NOMINATION

Nominee’s Name
Relationship to Age :
Date of Birth
the Proposer
Name of the Appointee Relationship to
Age :
(if nominee is a minor) the Nominee
( Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee )
I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository Yes No
If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number
If no, choose any one Insurance Repository
KARVY CAMSRep - CAMS Insurance Repository & Services CIRL - Central Insurance Repository Limited NDML - NSDL Data Management Services limited
Bank Details
of the
ProposerName of the Bank :
Account Name of the Branch : Type IFSC Code :
Please attach a photo copy of cancelled cheque leaf of the above Bank Account.
Number : of Account :  SB  CA  Others please specify
Payments Details Annual Premium Rs. Mode of Payment : Cash / Chque / DD / Credit Card / Debit Card / NEFT / CC Mandate

Cheque / DD No. : Date : Drawn on : Branch :

Please attach any one proof of Date of Birth :  Birth Certificate  Voter ID  PAN Card  Driving License  Aadhar Card  Any other Govt. Recognised Proof
Common Proposal Form 1 of 4
 Star Health and Allied Insurance Co. Ltd.
Insured person Details (Please fill in the respective column for each person proposed to be covered) Common Proposal Form

Details of the person proposed for insurance Insured Person - 1 Insured Person - 2 Insured Person - 3 Insured Person - 4 Insured Person - 5

Name Kailash Chandra Pandey

Gender M Date of Birth M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M/F/Thirdgender DD/MM/YYYY M/F/Thirdgender DD/MM/YYYY
15/12/1954
Height (cms) 172Cm Weight (kgs) 70 CMS KGS CMS KGS CMS KGS CMS KGS CMS KGS
Relationship with proposer Self

Occupation Annual Income (Rs.)

Sum Insured Opted (Rs.)

Add-ons : [Applicable for Mediclassic Insurance Policy

(Individual)] - Do you want add on covers - If Yes, Please tick
() (Patient Care add-on is available only for Insured
Hospital Cash Patient Care Hospital Cash Patient Care Hospital Cash Patient Care Hospital Cash Patient Care Hospital Cash Patient Care
Persons above 60yrs of age.)
and any other

1. Name of the Insurance Company

Existing Insura nce
Coverage with this

co mpany -details

2. Period of Insurance
co mpanygive

3. Sum Insured (Rs)

4. Policy No.
Detai ls of

1. Ailment for which Claim was made Year YYYY YYYY YYYY YYYY YYYY
Clai ms

2. Claim Amount Paid / Rejected

Health History :
Please provide answer in detail. A mere dash is not sufficient. Family Physician's Name Phone Regn No
1. Is the person proposed for insurance in good health
and free from physical and mental disease or infirmity.
If not give details
2. Has the person proposed for insurance consulted/
diagnosed /taken treatment /been admitted for any
illness/injury. If Yes, give details

3. Does the person proposed for insurance have any

complications during / following birth. If yes, please submit
all necessary documents.
4. Has the person proposed for insurance ever suffered or suffering from any of the following

a) Diabetes Mellitus - If Yes, since when

b) High BP, Cholesterol - If Yes, since when

c) Heart Disease - If Yes, since when

d) Stroke, epilepsy, fainting attack, chronic headache,
Parkinson's disease, Alzheimer's disease, - If Yes since
when
e) Tuberculosis, asthma, other respiratory infections - If
Yes, since when
f) Disease of bones /joints, slipped disc, spinal disorder,
injury to ligaments - If Yes, since when
g) Cancer, Pre Cancerous Lesion - If Yes, since when
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h) Gynecological disorder such as DUB, Fibroid Uterus,
Ovarian cyst - or have undergone cesarean / Hys-
terectomy If Yes, since when
 i) Treatment for sub fertility or has been advised for?
(answer if applicable) – If Yes provide details.
j) Disease of Stomach, Intestine, Liver, Gall bladder /
Pancreas, Kidney, Urinary bladder, Urinary Tract
Diseases - If Yes, since when
k) Disease of Prostrate / Fistula / Piles / Genital diseases -
If Yes, since when
l) Cataract and other diseases of the eye and ENT disease
- If Yes since when

m) Any Other Problem (Please Specify)

5. Has the person/s proposed for insurance

A). Undergone any medical test?
B).Prescribed any medicines? If yes
i). Name the illness for which medicines have been
prescribed

ii). Details of medicines and drugs

prescribed. iii). Period for which these drugs

were taken.

C).Been advised for any surgery / treatment ? - If Yes, give

details

D).Received /receiving any payment for any disability /

injury / illness/ disease. Give details

6. Does the a) Chew Tobacco - If Yes, since when

person
proposed b) Smoke - If Yes, since when
for
insurance c) Consume Alcohol - If Yes, since when
7. Is the person proposed for insurance positive for HIV If
yes, please mention your CD4count (Please attach proof)
Applicable for Star Comprehensive Insurance Policy
8. Does the Insured Occupation require to engage in manual
labour ?
9. Does the Insured Person engage in or propose to engage in any
activity or sport which is hazardous or adventurous in nature
such as Racing, Mountaineering, Winter sport etc if so please
specify

10. Name of the family member chosen for Personal Accident Insurance under
Section-7 (Note : The sum insured for personal accidental cover ( Accidental death & Permanent total disability) is by default Mr. / Ms.
equal to the sum insured opted for health cover. Personal Accident cover is not available for dependent children and for persons
above 70) years

Declaration of the Agent / Intermediary : I / We confirm that the product‘s suitability has been explained to the proposer. The information furnished in the proposal is true to the best of my knowledge and recommend acceptance of the proposal.
(Please Enclose Insurance Agent’s Confidential Report, If Any)
Name of the Agent / Specified
Person of Corporate Agent / Authorised Employee : Signature :

3 of 4
Code : of the Broker / Insurance Sales Person of the IMF
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 STAR HEALTH AND ALLIED INSURANCE COMPANY

Proposal Form No. :

LIMITED
Health
Insurance
The Health Insurance Specialist

Acknowledgement
Received the proposal for policy from Mr/ Mrs/ Ms. along with payment
Pe rs o n a l & C a r i n g

of Rs. /- by Cash / vide Cheque/ DD No. dt. drawn on . The Cash/Cheque given by you is banked for operational convenience and banking of the
Health
Cash/Cheque does not mean acceptance of risk by us. The receipt of the Cash/Cheque will also be acknowle dg e d b y o u r o ffi ce v id e advan c e p re m iu m receipt. If the proposal is accepted, the cover will commence from the date of the advance premium receipt, subject
P e r s o n a l & C a r in g I n the
to realization of the Cheque. If the proposal is not accepted, the amount paid will be refunded. Contact our office, in case policy is not received within 15 days from s udaterofapayment
n ceof premium.
Signature of the

Date : Place : The Health Insurance Specialist

Name & Code of the authorised person : authorised person
Common Proposal Form

Please Tick () the Policy Opted

 FAMILY HEALTH OPTIMA INSURANCE PLAN

UID No.: IRDAI/HLT/SHAI/P-H/[Link]/129/2017-18
 MEDICLASSIC INSURANCE POLICY (INDIVIDUAL)
UID No.: IRDA/NL-HLT/SHAI/P-H/[Link]/400/13-14
 SENIOR CITIZENS RED CARPET HEALTH INSURANCE POLICY
UID No.: SHAHLIP19101V031819

 STAR COMPREHENSIVE INSURANCE POLICY

POLICY UID No.: IRDA/NL-HLT/SHAI/P-H/[Link]/398/14-15

Sum Insured Options Available Rs. in Lakhs * (🗸) :


STAR CRITICARE PLUS INSURANCE POLICY
UID No.: IRDA/NL-HLT/SHAI/P-H/V.I/139/13-14
1  1.5 2 3 4
 STAR HEALTH GAIN INSURANCE POLICY
UID No.: IRDA/NL-HLT/SHAI/P-H(C)/V.I/138/13-14

5  7.5  10
 STAR FAMILY DELITE INSURANCE
UID No.: SHAHLIP18088V021718

 15  20  25
Family Size (A=Adult, C=Child) (🗸) :  1A  1A+1C  1A+2C  1A+3C  2A  2A+1C  2A+2C  2A+3C
* please check brochure for the available sum insured option in respect of each product.

Please affix photograph of Please affix photograph of Please affix photograph of Please affix photograph of Please affix photograph of
Insured Person - 1 Insured Person - 2 Insured Person - 3 Insured Person - 4 Insured Person - 5

Name :
Name : Name : Name : Name :

Declaration
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 insurance company and that the policy will come into force only after full receipt 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 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 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 Governmental and/or Regulatory authority. I confirm that the payment is made through my card / bank account. I also confirm that the source of funds for
premium paid under this policy is legal. In case of single Adult being covered along with children/child: I hereby confirm and warrant that I am single parent of the Child/Children proposed. I hereby confirm that the features of the product have been understood by me.
PRO / COMMON / V.2 /

Submitted the above proposal for policy along with payment of Rs. / by cash/vide cheque /DD no dated drawn on .
I understand that the cash/cheque given is banked for operational convenience and commencement of risk is subject to the acceptance of proposal by you.
Signature /
Place : Date: Name : Thumb
impression of
the proposer
WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE The contents of the proposal form and features of the :
 Prohibition of Rebates: Section 41 of Insurance Act 1938. 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 policy accept any rebate, except such
rebate as may be allowed in accordance with the published prospectuses or tables of the
insurer.
Any person making default in complying with the provisions of this section shall be liable for
4 of 4

Date Signature / Thumb impression of the proposer a penalty which may extend to ten lakh rupees.
Nameofofthe
Signature theperson
personwho
whoexplained
explained