Proposal Form URN : RHICL / R / HE / 041 / 19-20

‘G’ Proposal No.:_____________________

1. To be filled in by the Proposer in CAPITAL LETTERS only.

2. Care Health Insurance Limited (the “Company”) is under no obligation to accept any proposal for insurance or to issue a policy by mere submission of a completed proposal form and / or payment of proposal deposit towards the same.
The Company retains the right in its sole and absolute discretion to issue a policy. The liability of the Company does not commence until this Proposal has been accepted and underwritten by the Company and premium received, including loadings, if
any. You understand and agree that if the Company accepts a proposal for insurance, it shall be subject to the Policy Terms and Conditions and the Company shall have no liability whatsoever if the premium is not realized, or received in full or in time. In
the event the Company does not accept the proposal, you will be informed of the same and the premium received (less costs of medical tests) from you, if any, will be refunded without interest.
3. If there is insufficient space, please provide further details on a separate sheet. All attached documents form part of this Proposal.

FOR OFFICE USE ONLY

Intermediary Details
Intermediary Code : Intermediary Name :
Intermediary RM Code : Branch Code :
Customer Acc No. :
Care Health Insurance Branch Details
CHI RM Name :
Branch Code : Client ID : Receipt ID :

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Details of ‘Point of Sales’ Person : (To be filled in if the Policy is sourced through ‘Point of Sales’ Person)
Please furnish at least one of the following details of “Point of Sales” Person:
Aadhar Card No.: PAN Card No.:

PROPOSER DETAILS

Name : (Mr./Ms./Mrs.)

Key Person Name : (Mr./Ms./Mrs.)

Correspondence Address :

Locality :
Pin Code :
Landmark :
(First Name)

(First Name)
PL State :
(Middle Name)

(Middle Name)

City :
(Last Name)

(Last Name)
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Permanent Address :
If same as above, please tick here

Locality : City :
Pin Code : State :
Telephone : Mobile :
Alternate No. :
Email :
D D M M Y Y Y Y
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Date of Birth / Incorporation (in case Proposer is an entity) : Gender : Male Female Others
Marital Status : Single Married Divorced Widow(er) Separated
PAN Number : Nationality :
Form 60 (only in case the customer does not have PAN no.) : Yes No Aadhaar Number :
(By signing the Proposal form I give my consent for using my Aadhaar No. for Authentication of my Aadhaar Details)

Mother’s Name :

Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? Yes No
If you have an eIA, please provide following details:
I) Name of Insurance Repository :
ii) eIA No :
iii) Name as appearing in eIA :

If you do not have an eIA, would you like to open an account? Yes No
If Yes, choose any one Insurance Repository:
NDML – NSDL Data Management Limited CAMSRep- CAMS Repository Services Limited
Karvy Insurance Repository Limited CIRL-Central Insurance Repository Limited ( CDSL)
Help us preserve the environment by opting to receive policy related information in soft copy/via email only : Yes No
Would you like to Subscribe to important alert on Whatsapp? Yes No
Ver: Jul/20

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655
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CIN: U66000DL2007PLC161503 UIN: IRDA/NL-HLT/RHI/P-H/V.I/305/13-14 IRDA Registration No. - 148
 POLICY DETAILS
Proposed Policy Period Start Date : D D M M Y Y Y Y Plan Opted :
Sum Insured (in Rs.) : Deductible :
Cover Type : Individual Floater Tenure : 1 Year 2 Year 3 Year
Everyday Care Add-on Benefit : Yes No
Expert Opinion Add-on Benefit : Yes No
Are you applying for portability? Yes No (If yes, please fill in the separate Portability Form)

NOMINEE DETAILS
Nominee Name Date of Birth (DD/MM/YYYY) Relationship with Proposer

*If the Nominee is of Age 18 years or less, Name of Appointee and Relationship with Minor:
Appointee Name Date of Birth (DD/MM/YYYY) Relationship with Minor

In event of the death of the Proposer any payment due under the policy shall become payable to the nominee proposed in this form. The receipt of the proceeds by the Nominee would be sufficient discharge to the company. Nominee for all the
other person(s) proposed to be insured shall be the Proposer himself.

DETAILS OF THE PERSONS TO BE INSURED INCLUDING PROPOSER

Insured 1 : Name : Mr./Ms./Mrs.

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Marital Status Date of Birth D D M M Y Y Y Y Height : cms Weight : kg
Gender Male Female Others Aadhaar No. (Optional) If PEP* : Yes No
Relationship with Proposer : Address : Occupation : Self employed Service
Insured 2 : Name : Mr./Ms./Mrs.
D D M M Y Y Y Y cms kg
Marital Status
Gender

Marital Status
Gender
Male
Relationship with Proposer :
Insured 3 : Name : Mr./Ms./Mrs.
Marital Status
Gender Male
Relationship with Proposer :
Insured 4 : Name : Mr./Ms./Mrs.

Male
Female

Female

Female
Others

Others

Others
Date of Birth
Aadhaar No. (Optional)

Date of Birth
Address :

Aadhaar No. (Optional)

Date of Birth
Address :
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D D M M Y Y Y Y

D D M M Y Y Y Y
Aadhaar No. (Optional)
Height :

Height :

Height :
cms

cms
Weight :
If PEP* :
Occupation : Self employed

Weight :
If PEP* :
Occupation : Self employed

Weight :
If PEP* :
Yes

Yes

Yes
Service

kg

Service

kg
No

No

No
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Relationship with Proposer : Address : Occupation : Self employed Service
Insured 5 : Name : Mr./Ms./Mrs.
Marital Status Date of Birth D D M M Y Y Y Y Height : cms Weight : kg
Gender Male Female Others Aadhaar No. (Optional) If PEP* : Yes No
Relationship with Proposer : Address : Occupation : Self employed Service
Insured 6 : Name : Mr./Ms./Mrs.
Marital Status Date of Birth D D M M Y Y Y Y Height : cms Weight : kg
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Gender Male Female Others Aadhaar No. (Optional) If PEP* : Yes No

Relationship with Proposer : Address : Occupation : Self employed Service

*Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior
executives of state owned corporations or important political party officials.

Please fill the following details :

Details Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6
Is any of the member proposed to be insured suffering from any illness or
Y N Y N Y N Y N Y N Y N
disease? If yes, please provide details.

MEDICAL / LIFESTYLE RELATED INFORMATION

Particulars Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6
Does any proposed insured currently or in pas t
Diagnosed/Suffered/Treated/Taken Medication for any of the following
conditions: If yes, please provide details in the additional information
section below:
Y N Y N Y N Y N Y N Y N
1. Cancer, tumor, polyp or cyst
Since_____ Since_____ Since_____ Since_____ Since_____ Since_____

2. Any heart disease or disorder, chest pain or discomfort, irregular Y N Y N Y N Y N Y N Y N

heart beats, palpatations or heart murmur Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
Y N Y N Y N Y N Y N Y N
3. Hypertension / High Blood Pressure(BP)/ High Cholestrol
Since_____ Since_____ Since_____ Since_____ Since_____ Since_____

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4. Asthma / Tuberculosis (TB) / COPD/ Pleural effusion / Bronchitis / Y N Y N Y N Y N Y N Y N
Emphysema or any other disease of Lungs, Pleura and airway or
Respiratory disease ? Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
5. Thyroid disease/ Cushing's disease/ Parathyroid Disease/ Addison's Y N Y N Y N Y N Y N Y N
disease / Pitutiary tumor/ disease or any other disorder of Endocrine
system ? Since_____ Since_____ Since_____ Since_____ Since_____ Since_____

6. Diabetes Mellitus / High Blood Sugar / Diabetes on Insulin or Y N Y N Y N Y N Y N Y N

medication Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
7. Motor Neuron Disease/ Muscular dystrophies/ Myasthnia Gravis or Y N Y N Y N Y N Y N Y N
any other disease of Neuromuscular system (muscles and/or nervous
system) Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
8. Stroke/ Paralysis/ Transient Ischemic Attack/ Multiple Sclerosis/ Y N Y N Y N Y N Y N Y N
Epilepsy/ Mental-Psychiatric illness/ Parkinsonism/ Alzeihmer's/
Depression / Dementia or any other disease of Brain and Nervous System? Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
9. Cirrhosis / Hepatitis / Wilson’s disease / Pancreatitis / Liver disease /
Crohn's disease / Ulcerative Colitis /Piles or any other disease of Y N Y N Y N Y N Y N Y N
Mouth, Esophagus, Liver, Gall bladder, Stomach or Intestines or any Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
other part of Digestive System?
10. Kidney Stones/ Renal Failure/ Dialysis/ Chronic Kidney Y N Y N Y N Y N Y N Y N
Disease/Prostate Disease or any other disease of Kidney, Urinary
Tract or reproductive organs? Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
11. HIV/SLE/ Arthiritis/ Scleroderma / Psoriasis/ bleeding or clotting Y N Y N Y N Y N Y N Y N

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disorders or any other diseases of Blood, Bone marrow/ Immunity or
Skin. Since_____ Since_____ Since_____ Since_____ Since_____ Since_____

12. Disease or disorder of eye, ear, nose or throat (except any sight Y N Y N Y N Y N Y N Y N
related problems corrected by prescription lenses)? Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
13. Smoke, consume alcohol, or chew tobacco, ghutka or paan or use any Y N Y N Y N Y N Y N Y N
recreational drugs? If 'Yes' then please indicate the following:
Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
-
-
-
-
-
Hard Liquor (No. of Pegs in 30 ml per week)
Beer(Bottles/ml per week)
Wine( Glasses/ml per week)
Smoking (no. of Sticks per day)
Gutka/Pan Masala/Chewing Tobacco(Sachets/Grams per day)

14. Any other disease / health adversity / injury/ condition / treatment not
mentioned above?
15. Has any of the Proposed to be Insured been hospitalized
/recommended to take investigations/medication or has been under
any prolonged treatment/ undergone surgery for any illness/injury
other than for childbirth/minor injuries?
PLY
Since_____

Y
Since_____
N

N
Y N
Since_____

Y N
Since_____
Y
Since_____

Y
Since_____
N

N
Y
Since_____

Y
Since_____
N

N
Y
Since_____

Y
Since_____
N

N
Y N
Since_____

Y N
Since_____
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Note: The Company shall reject Your proposal and refund the premium amount (after deducting cost of medical tests, if any) in case of incompleteness or any discrepancy highlighted or any
other reason.
The Company may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the members proposed to be insured). These
loadings would be applied from the Policy Period Start Date including all subsequent renewals with the Company.
Any loadings, if applicable, shall be suitably intimated to the Proposer based on the assessment of the proposal form and medical tests. The Proposer shall be required to pay an additional
premium within 15 days of such intimation.
The Company shall not be at any risk during this period. In the event of non-receipt of this additional premium within the stipulated time, Company shall cancel your proposal and refund the
premium amount after deducting cost of medical tests, if any.

ADDITIONAL INFORMATION (IF YOUR ANSWER IS ‘YES’ TO ANY OF THE ABOVE QUESTIONS OR THE PROPOSED TO BE
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INSURED ARE SUFFERING FROM ANY OTHER PRE EXISITNG DISEASE WHICH IS NOT MENTIONED IN THE ABOVE LIST)

DETAILS OF PREVIOUS OR EXISTING HEALTH INSURANCE

Please fill the following details with respect to health insurance proposals/policies with the Company or any other insurance companies
Details Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6
Have any of the person(s) to be insured ever filed a claim with their
current/previous insurer? If Yes, please provide details on a separate sheet Y N Y N Y N Y N Y N Y N
Has any of your proposal(s) for Health insurance been declined,
cancelled, charged a higher premium or issued with special condition(s)? Y N Y N Y N Y N Y N Y N

Y N Y N Y N Y N Y N Y N
Is any of the person(s) proposed for insurance covered under any other
health insurance policy with the Company or any other Company without Since_____ Since_____ Since_____ Since_____ Since_____ Since_____
break?
(DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY) (DD/MM/YYYY)

ATTENDING PHYSICIAN'S DETAILS

Name of Family Physician :
(First Name) (Middle Name) (Last Name)
Contact Number : Email :

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655
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CIN: U66000DL2007PLC161503 UIN: IRDA/NL-HLT/RHI/P-H/V.I/305/13-14 IRDA Registration No. - 148
 DECLARATION
a. 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.
b. 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.
c. 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.
d. 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 affects 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.
e. 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.

Date : / / (DD/MM/YYYY) Signature of the Proposer :______________________________________

Place : (On behalf of all the persons to be insured under the Policy)

NEFT DETAILS (FOR CLAIMS & REFUND PURPOSES)

Account Number : IFSC Code :
Bank Name : Bank Branch Name :
Name of the Account Holder :

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Note : Please submit copy of cancelled cheque along with Proposal Form
I declare that the information given above is true and correct. I hereby authorize Care Health Insurance Limited to directly credit payout/refund, if any, to the above mentioned account and I shall not hold Care Health Insurance Limited
responsible for non-credit/non-payment of payout or refund, if any, due to any reason including but not limited to incorrect/incomplete information. Care Health Insurance Limited reserves right to use any alternative payout option such as
cheque/demand draft in spite of providing above information.

Date : / / (DD/MM/YYYY) Signature of the Proposer :______________________________________

Place : (On behalf of all the persons to be insured under the Policy)

PREMIUM PAYMENT INFORMATION

Payment By Cash / Cheque / Demand Draft / Card (Strike out whichever is not applicable) :
Cheque / Demand Draft No. / Authorization ID :
Payment Amount (`) :
Date : Bank Name :
PL Premium Amount (`) :

In case of payment through Cheque / Demand Draft, the instrument should be drawn in favour of “Care Health Insurance Ltd.”
Key Exclusions :
(I)
(ii)
Any disease contracted during the first 30 days of the policy start date, except those arising out of accidents.
2 Year Wait Period : Non-infective arthritis/Joint replacement/Cataract/Piles/Fissure/Ear, nose and throat (ENT) disorders and surgeries/Stones, etc.
(iii) Pre-existing Diseases : 48 months from the date of the first policy
(iv) Permanent Exclusions : Non-allopathic treatment / Expenses attributable to self-inflicted injury (resulting from suicide, attempted suicide) or alcohol or drug use, misuse or abuse / Cost of spectacles, contact lenses / Medical expenses incurred
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for treatment of AIDS / Treatment arising from or traceable to pregnancy and childbirth, miscarriage, abortion and its consequences or relating to infertility and in vitro fertilization / Congenital disease.
(v) Treatment/consultation in a hospital which is named in the negative list of hospitals.
For a detailed set of exclusions, please log on to www.careinsurance.com.
Note: Should you choose to pay premium by cash, you are advised to do so only at the nearest Care Health insurance limited branch or any authorized Bank branch, and we insist you to please ask for computerize receipt against the deposited cash against
your Proposal. Any claim without computerized receipt against the deposited cash will not be admitted.

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 policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or
tables of the Insurer.
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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 FOR AGENTS

I ____________________________________________ (Full Name) 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 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 vary the benefits which may be payable as per Policy
Terms and Conditions and furthermore, 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. (Advisor/Corporate Agent/Broker/Relationship Officer):

Date : / / (DD/MM/YYYY) Signature : ______________________________________________

SP Name : _________________________________________________ SP Code :

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655
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CIN: U66000DL2007PLC161503 UIN: IRDA/NL-HLT/RHI/P-H/V.I/305/13-14 IRDA Registration No. - 148
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Acknowledgement for Proposal

Please retain this counterfoil for your records (On behalf of Care Health Insurance Limited)
We acknowledge the receipt of payment of `______________________ vide Cash/Cheque/DD No./Authorization ID___________________________________ from
Mr./Ms._______________________________________________.

Please note that this is only an acknowledgement receipt and does not amount to acceptance of risk or commencement of the Policy. The Company is not liable for any claim between the time that the
proposal amount is received and Policy Start Date. The validity of this receipt is subject to realization of the proposal amount. Acceptance of proposal and issuance of the Policy shall be subject to receipt of
the completed Proposal Form, premium payment, medical reports (wherever applicable) and underwriting decision of the Company.

Proposal No.: ______________________________ Signature of the Representative : _____________________________________

Name of the Representative : _____________________________________________________
Insurance is a subject matter of solicitation. IRDA Registration No. 148
Note: Should you choose to pay premium by cash, you are advised to do so only at the nearest Care Health insurance limited branch or any authorized Bank branch, and we insist you to please ask for computerize
receipt against the deposited cash against your Proposal. Any claim without computerized receipt against the deposited cash will not be admitted.
Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House,Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488 | 1800-102-6655
Page 5
CIN: U66000DL2007PLC161503 UIN: IRDA/NL-HLT/RHI/P-H/V.I/305/13-14 IRDA Registration No. - 148