Photograph
UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014
DIVISIONAL / BRANCH OFFICE.............................................
SUPER TOP UP MEDICARE PROPOSAL FORM
AGENCY CODE ANNUAL PREMIUM POLICY NO
DEV. OFFICER CODE
IMPORTANT
a) The Company will not be on risk until the proposal and Insured Persons details have been
accepted by the Company and communication of the acceptance has been given to the
proposer in writing on full payment of premium
b) If other family members residing with proposer i.e., spouse and eligible dependent
children required to be covered, separate Insured Person details forms should be
completed for each of such family members.
c) Persons may be required to undergo pre-acceptance health check-up at a recognised
Hospital/Nursing Home/Laboratories/Clinic at the cost of insured in some cases as
mentioned in the prospectus.
d) Fresh proposal form is required along with pre-acceptance medical check-up as
mentioned in item (c) above, irrespective of age, when there is break in insurance cover
or when there is a request for enhancement in the sum insured.
e) Non-disclosure of facts material to the assessment of the risk, providing misleading
information, fraud or non-co-operation by the insured will nullify the cover under the
policy (material fact is one which will enable the Insurer to decide whether to accept
the risk and if yes, at what rate, terms and conditions.
f) Please fill up the proposal form completely. If space is insufficient, separate sheet
may be attached wherever required.
PROPOSER DETAILS
1. Name of the proposer ………………………. ………………………….
(Surname) (Name)
2. Residential Address and :
Telephone No
3. Occupation (Profession/Occupation/
Trade/ or Business) :
Name of Office & Address :
4. Monthly Income :
5. Income-Tax PAN No. :
6. Name of the Medical Practitioner, his
qualifications & Telephone no. if any
Medical Practitioner's Regn. No. :
7. Total number of Persons to be covered (in figures) :
(in words) :
Details of Insured Persons and their specimen signatures
[Link] Name of Insured Person Date of Age Sex Relation Signature
Birth
1
3
4
5
Photographs of Insured persons:
Photograph Photograph Photograph Photograph Photograph
8. Do you wish to have Policy on : Individual basis or Family Floater basis
9. If on family floater basis, choose any one :
([Link] to Prospectus for definition of family. Parents have
to be covered under separate policy)
Self, spouse and children
Parents
Indicate option:A / B / C / D / E / F / G / H
10 If on Individual basis, indicate option for each individual person
1 Self - A/B/C/D/E/F/G/H
2 Spouse - A/B/C/D/E/F/G/H
3 Child –1 - A/B/C/D/E/F/G/H
4 A/B/C/D/E/F/G/H
5 A/B/C/D/E/F/G/H
6 A/B/C/D/E/F/G/H
11. Period of Insurance From To (midnight)
12. Are any of the insured persons at present or have been at any other time in the past
covered (Please note that this information is required to decide the coverage of Pre-Existing
Disease in this policy. This information may be cross-verified at a later date)
I Under any other Insurance
Type (Cancer Insurance, Hospitalisation Insurance
Or other Medical Insurance), If so,
(A) Give particulars of current or expiring policy as well as for the previous four years
Insurer Policy No. Expiry date Sum Insured Pre existing TPA
(RS.) Diseases, if
any
Date of first coverage which has since been renewed continuously
without break or within grace period ----
II Under any Medical expenses Reimbursement Scheme : YES/NO
(IMP : A brief note giving details of the Scheme will help
in better evaluation of your proposal).
Please furnish the following – (strike off wherever not applicable)
a. Scheme Provided by : Employer / Others
Name of the Employer :
Others :
b. Persons covered : All those who are proposed for coverage
under this policy
or
only some persons.
c. Expenses reimbursed : Any Hospitalisation / Only Specified Diseases
d. Amounts :
Names of the persons Eligible Reimbursement Remarks
covered under the Scheme amount
13 Claim amounts received/receivable in preceding five years including expiring
policy/Reimbursement Scheme
Name of the Policy Period Illness Claimed Amount TPA, if
Insurer / No./ of amount settled/pend applicable
Reimbursement Scheme Hospitali ing for
Provider Name sation settlement
14. Has any Proposal for this Insurance or any other health insurance been refused
Or cancelled or higher premium charged. If so give details:
15.1 Are all the insured persons are in good health and free from
Physical and mental diseases or infirmity
Or medical complaints?
15.2 If not in good health give full details
S.N. Name of Nature of illness / Date first Name of attending Whether fully
the disease injury and treated medical practitioner, cured
insured treatment surgeon with his
persons received address and Telephone
No.
1.
2.
3.
16 Are there any additional facts affecting
the proposed insurance which should
be disclosed to Insurers ? -----------------
17. Please give details of any knowledge of any positive
Existence or presence of any ailment, sickness
Or injury which may require medical attention.
1.
2.
3.
4.
I hereby declare and warrant that the above statements are true and complete. I consent and
authorise the Insurers to seek medical information from any Hospital / Medical Practitioner
who has at any time attended or may attend concerning any disease or illness which affects the
physical or mental health of any insured persons. I agree that this proposal shall form the basis
of the contract should the insurance be effected. If after the insurance is effected, it is found
that the statements, answers or particulars stated in the Proposal form and its questionnaires
are incorrect or untrue in any respect, the Insurance Company shall incur no liability under this
insurance.
I have read the Prospectus and am willing to accept the coverage subject to the terms,
conditions and exceptions stated therein and expressed in the Policy.
Signature ---------------------------- Date ------------ / ---------- / ----------
Place: -----------------------
PLACE:
DATE: Signature of the proposer
Section 41 OF INSURANCE ACT 1938
PROHIBITION OF REBATES <
4. 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 a part of commission
payable or any rebates of the premium- shown on the policy nor shall any person taking
out or renewing continuing a policy except any rebate as may be allowed in accordance
with the published prospectus or tables of the insurer.
5. Any person making default in complying with the provisions of this section shall be
punishable with fine which may extend to five hundred rupees.
