THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001

Grmed.07 - 01

PROPOSAL FORM FOR GROUP MEDICLAIM POLICY (2007)
(TO BE COMPLETED BY THE GROUP PROPOSING FOR INSURANCE)

R.O./D.O./B.O.
Agency Code: Annual Premium
Policy No. Inspector Code
IMPORTANT
a. The company will not be on risk until the Proposal has been accepted by the
Company and full premium paid by CHEQUE.
b. Employee’s/Member’s Personal Statement Form should be completed by each
employee/member for himself/herself and his/her eligible family members, as per
Annexure.
c. 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 issued.
PROPOSER DETAILS
1. Name of the Proposer
(Capital letters)
2. Description of the Proposer’s business
3. Address for communication
Tel.No: Fax No: E-mail Add.
4. Please state whether all eligible members of the Group are Proposed for Insurance.
5. No. of persons to be covered (list of Persons for each Sum Insured opted as per table)
Sr. No.
Employee
No./Family
Member
Name Date of
Birth
Sum Insured
2
6. Do you require Maternity Expenses: Yes/No
Benefit Extension (strike out whichever is
Not applicable)
7. Zone Opted for treatment:
8. Period of Insurance: From
To (midnight)
Signature of the Proposer
Place:
Date:
Section 41 of Insurance Act, 1938
Prohibition of Rebates
1) No person shall allow or offer to allow either directly or indirectly as an inducement of
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 except any rebate except such rebate as may be
allowed in accordance with the prospectus or tables of the insurer.
2) Any person making default in complying with the provisions of this Section shall be
punishable with fine, which may extend to five hundred rupees.