STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Acknowledgement
Received the proposal for STAR TRUE VALUE HEALTH INSURANCE POLICY from Mr/ Mrs/ Ms.__________________________________________________________________ along with payment 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 Cash/Cheque does not mean acceptance of risk
Proposal Form No.:

by us. The receipt of the Cash/Cheque will also be acknowledged by our office vide collection receipt. If the proposal is accepted, the cover will commence from the date of the collection receipt, subject 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 the date of payment of premium.
Name & Code of the Signature of the
Date: Place: authorised person: authorised person:

Please affix Please affix Please affix Please affix

stamp size stamp size stamp size stamp size
photograph photograph photograph photograph
of Insured of Insured of Insured of Insured
Person - 1 Person - 2 Person - 3 Person - 4

Declaration

Star True Value Health Insurance Policy

1. 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. 2. 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. 3. 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. 4. I declare that I consent to the company
seeking medical information from any doctor or from a hospital who/which at anytime 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. 5. 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. 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. I hereby confirm that the features of the product have been understood by me. I hereby authorize Star Health and Allied Insurance Company to contact me. It will override my registry on the NCPR.

Submitted the above proposal for STAR TRUE VALUE HEALTH INSURANCE 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.

Place Date Name

Signature / Thumb
impression of the
proposer:

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE LANGUAGE The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
OF THE PROPOSAL FORM. the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
have fully understood the significance of the an inducement to any person to take out or renew or continue an
I hereby confirm that the details have been explained to the proposer insurance in respect of any kind of risk relating to lives or property in
proposed contract.
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
Date Name of the person who explained Signature of the person who explained Signature / Thumb impression of the proposer section shall be liable for a penalty which may extend to ten lakh rupees.

4 of 4
NOMINATION
TYPE

of the
Mobile

Details

DD No.
Number

Cheque /
Proposer

Payments
Name
BUSINESS

Bank Details
Mr / Mrs / Ms.

PAN Number

Nominee’s
Period of Insurance
Residential Address:

Bank
Insurance Repository
Name of the Proposer

other electronic mode

Amount
Number
Policy Issuing Office:

Account

Premium
(if nominee is a minor)
Name of the Appointee
Occupation of the Proposer

Name of the
Do you have a CKYC number

Sum Insured Options Available

Rs.

Star True Value Health Insurance Policy

From

q
c YES
INSURANCE POLICY
UIN No.: SHAHLIP21177V022021
Unique Reference No.: SHAI/PR0018
STAR TRUE VALUE HEALTH

If Yes : q a. Unorganized Sector

If you don’t have an (elA) number, choose any one

c NO

Rs.30,000/-
q c. Other Categories of Persons
Ref. No.

AGENT /
AGENT /

Pin Code:
Policy No.

SM CODE

BROKER /

Date
IMF / CODE

q
CORPORATE

Branch
Email ID

Rs.40,000/-

Please attach a photo copy of cancelled cheque leaf of the above Bank Account.
q d. Informal Sector

to Nominee
to Proposer

Name of the
Relationship
Relationship
GST Number

Do you wish to receive the copy of the policy document by Email / Whatsapp / Any
If yes Please mention the number

To

on
n CDSL Insurance Repository Limited
n Karvy Insurance Repository Limited

Drawn
q
b. “Economically Vulnerable or Backward Classes” means persons who live below the poverty line.

work mostly labour intensive, having often unwritten and informal employer-employee relationship.
Office Address:

PRO / TVH / V.8 / 2022

■ YES ■ NO
Do you come under below mentioned Social Sector Classification*: q Yes q No

Rs.60,000/-
Annual
Income

q b. Economically Vulnerable or Backward Classes

AGENT /

AGENT /
BROKER /
SM NAME

IMF / NAME
Date of Birth

IFSC
CORPORATE

Code
Birth
Birth

Branch
Date of
Date of

q
Rs.

(Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee)
Rs.70,000/-

copy of the policy document

I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository
Are you a ASHA workers

DD/MM/YYYY
DD/MM/YYYY
Are you a MGNREGA workers

Do you wish to receive the physical

Proposal Form No.:

Pin Code:

q
DD/MM/YYYY
Chennai - 600 034. « Phone : 044 - 28288800 « Email : support@[Link]

Act, 1995 and who may not be gainfully employed; and also includes guardians who need insurance to protect spastic persons or persons with disability.

Age
Age
q YES
q YES
Website : [Link] « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129
Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,

n NSDL National Insurance Repository (NIR)

collectors, toddy tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and coolies or such other categories of persons.
Rural and Social Sector Classification

Rs.80,000/-
* “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural and urban areas;

n CAMS Insurance Repository Services Limited

Please fill up the form in block letters.

Mode of Payment : Cash / Cheque / DD / Credit Card / Debit Card / NEFT / CC Mandate / ECS
q NO
q NO

Please attach any one proof of Date of Birth : q Birth Certificate q Voter ID q PAN Card q Driving License q Aadhar Card q Any other Govt. Recognised Proof
■ YES ■ NO
■ YES ■ NO
and income, with heterogeneous activities like retail trade, transport, repair and maintenance, construction, personal and domestic services and manufacturing, with the
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
c. “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)
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
a. “Unorganised sector” includes self-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers,
payment of premium has been received.
proposal has been accepted and full

Yrs
Yrs
The company will not be on risk until the

1 of 4
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Type of Account : q SB q CA q Others please specify __________________

If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number:_____________________________________________________
Star True Value Health Insurance Policy

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

Name

Gender 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

Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS

Relationship with proposer

Occupation Annual Income (Rs.)

1. Name of the Insurance Company

Existing Insurance 2. Period of Insurance

Coverage with this
company and any
other company -
give details 3. Sum Insured (Rs)

4. Policy No.

1. Ailment for which Claim was

Year YYYY YYYY YYYY YYYY
Details made
of
Claims
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 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
2 of 4

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

Star True Value Health Insurance Policy

h) Gynecological disorder such as DUB, Fibroid Uterus,

Ovarian cyst - or have undergone cesarean / Hysterectomy If
Yes, since when
i) Disease of Stomach, Intestine, Liver, Gall bladder / Pancreas,
Kidney, Urinary bladder, Urinary Tract Diseases - If Yes, since
when

j) Disease of Prostrate / Fistula / Piles / Genital diseases - If Yes,

since when

k) Cataract and other diseases of the eye and ENT disease - If

Yes since when

l) 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

a) Chew Tobacco - If Yes, since when

6. Does the
person
proposed b) Smoke - If Yes, since when
for
insurance
c) Consume Alcohol - If Yes, since when

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.
Name of the Agent / Specified Person of Corporate Agent / Broker Signature of the Agent / Specified Person of Corporate Agent / Broker
3 of 4

(Please Enclose Insurance Agent’s Confidential Report, If Any) Code

Qualified Person / Insurance Sales Person of the IMF / Qualified Person / Insurance Sales Person of the IMF
Star True Value Health Insurance Policy

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

Name

Gender 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

Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS

Relationship with proposer

Occupation Annual Income (Rs.)

1. Name of the Insurance Company

Existing Insurance 2. Period of Insurance

Coverage with this
company and any
other company -
give details 3. Sum Insured (Rs)

4. Policy No.

1. Ailment for which Claim was

Year YYYY YYYY YYYY YYYY
Details made
of
Claims
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 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
2 of 4

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

Star True Value Health Insurance Policy

h) Gynecological disorder such as DUB, Fibroid Uterus,

Ovarian cyst - or have undergone cesarean / Hysterectomy If
Yes, since when
i) Disease of Stomach, Intestine, Liver, Gall bladder / Pancreas,
Kidney, Urinary bladder, Urinary Tract Diseases - If Yes, since
when

j) Disease of Prostrate / Fistula / Piles / Genital diseases - If Yes,

since when

k) Cataract and other diseases of the eye and ENT disease - If

Yes since when

l) 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

a) Chew Tobacco - If Yes, since when

6. Does the
person
proposed b) Smoke - If Yes, since when
for
insurance
c) Consume Alcohol - If Yes, since when

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.
Name of the Agent / Specified Person of Corporate Agent / Broker Signature of the Agent / Specified Person of Corporate Agent / Broker
3 of 4

(Please Enclose Insurance Agent’s Confidential Report, If Any) Code

Qualified Person / Insurance Sales Person of the IMF / Qualified Person / Insurance Sales Person of the IMF
 Proposal Form No.:
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
Acknowledgement
Received the proposal for STAR TRUE VALUE HEALTH INSURANCE POLICY from Mr/ Mrs/ Ms.__________________________________________________________________ along with payment 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 Cash/Cheque does not mean acceptance of risk
by us. The receipt of the Cash/Cheque will also be acknowledged by our office vide collection receipt. If the proposal is accepted, the cover will commence from the date of the collection receipt, subject 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 the date of payment of premium.
Name & Code of the Signature of the
Date: Place: authorised person: authorised person:
Star True Value Health Insurance Policy

Please affix Please affix Please affix Please affix

stamp size stamp size stamp size stamp size
photograph photograph photograph photograph
of Insured of Insured of Insured of Insured
Person - 1 Person - 2 Person - 3 Person - 4

Declaration
1. 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. 2. 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. 3. 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. 4. I declare that I consent to the company
seeking medical information from any doctor or from a hospital who/which at anytime 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. 5. 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. 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. I hereby confirm that the features of the product have been understood by me. I hereby authorize Star Health and Allied Insurance Company to contact me. It will override my registry on the NCPR.

Submitted the above proposal for STAR TRUE VALUE HEALTH INSURANCE 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.

Place Date Name

Signature / Thumb
impression of the
proposer:

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE LANGUAGE The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
OF THE PROPOSAL FORM. the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
have fully understood the significance of the an inducement to any person to take out or renew or continue an
I hereby confirm that the details have been explained to the proposer. insurance in respect of any kind of risk relating to lives or property in
proposed contract.
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.
4 of 4

2. Any person making default in complying with the provisions of this

Date Name of the person who explained Signature of the person who explained Signature / Thumb impression of the proposer section shall be liable for a penalty which may extend to ten lakh rupees.
Star True Value Health Insurance Policy

(Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee)

NOMINATION
Please attach any one proof of Date of Birth : q Birth Certificate q Voter ID q PAN Card q Driving License q Aadhar Card q Any other Govt. Recognised Proof
DD No.
Cheque /
Details
Payments
Please attach a photo copy of cancelled cheque leaf of the above Bank Account.

Proposer
of the
Bank Details Number

Insurance Repository
If you don’t have an (elA) number, choose any one
If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number:_____________________________________________________

I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository

other electronic mode

Do you wish to receive the copy of the policy document by Email / Whatsapp / Any
Sum Insured Options Available

Period of Insurance

TYPE
BUSINESS

Do you have a CKYC number

PAN Number

Number
Mobile

Residential Address:

Occupation of the Proposer

Mr / Mrs / Ms.
Name of the Proposer
* “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural and urban areas;

Policy Issuing Office:

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

c. “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)
b. “Economically Vulnerable or Backward Classes” means persons who live below the poverty line.

a. “Unorganised sector” includes self-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers,
(if nominee is a minor)
Name of the Appointee
Name
Nominee’s

STAR TRUE VALUE HEALTH

Unique Reference No.: SHAI/PR0018
UIN No.: SHAHLIP21177V022021
work mostly labour intensive, having often unwritten and informal employer-employee relationship.
and income, with heterogeneous activities like retail trade, transport, repair and maintenance, construction, personal and domestic services and manufacturing, with the

Act, 1995 and who may not be gainfully employed; and also includes guardians who need insurance to protect spastic persons or persons with disability.

collectors, toddy tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and coolies or such other categories of persons.
handicapped self-employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane cutters, tendu leaf
fishermen, hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather and tannery workers, papad makers, powerloom workers, physically

INSURANCE POLICY
Premium
Annual

Bank
Name of the

Account

If Yes : q a. Unorganized Sector

Do you come under below mentioned Social Sector Classification*: q Yes q No
q c. Other Categories of Persons
Rs.

c YES
From
q

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Rs.30,000/-

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
c NO

Website : [Link] « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129

Chennai - 600 034. « Phone : 044 - 28288800 « Email : support@[Link]
Pin Code:
n CIRL - Central Insurance Repository Limited
n KARVY

IMF / CODE
BROKER /
AGENT /
CORPORATE
AGENT /
SM CODE

Policy No.

Ref. No.
If yes Please mention the number
Date

q d. Informal Sector
q b. Economically Vulnerable or Backward Classes
q
Rs.40,000/-
Mode of Payment : Cash / Cheque / DD / Credit Card / Debit Card / NEFT / CC Mandate / ECS

Branch
Name of the

to Nominee
Relationship
to Proposer
Relationship

GST Number

Email ID
PRO / TVH / V.8 / 2022

Type of Account : q SB q CA q Others please specify __________________

To

Office Address:
■ YES ■ NO
Drawn
on

q
Rs.60,000/-

Income
Annual

Date of Birth

IMF / NAME
BROKER /
AGENT /
CORPORATE
AGENT /
SM NAME
n NDML - NSDL Data Management Services limited
n CAMSRep - CAMS Insurance Repository & Services

copy of the policy document

Do you wish to receive the physical
Code
IFSC
Branch

Birth
Date of
Birth
Date of

Are you a MGNREGA workers

Are you a ASHA workers
q

Please fill up the form in block letters.

Rs.

payment of premium has been received.

proposal has been accepted and full
The company will not be on risk until the
Rural and Social Sector Classification
Rs.70,000/-

Proposal Form No.:

DD/MM/YYYY

DD/MM/YYYY

Pin Code:

DD/MM/YYYY
q
■ YES ■ NO
■ YES ■ NO

q YES
q YES
Age

Age
Rs.80,000/-

q NO
q NO
1 of 4

Yrs

Yrs