National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

BARODA HEALTH POLICY

PROPOSAL FORM

1) Bank of Baroda Branch Office:______________________ Branch Code No.____________

2) Name of the Proposer:_____________________________________________

3) SB/CA Account No.:_______________________________________________

4) Postal Address and Telephone No._________________________________________
_____________________________________________________________________________________________________________________________________________

5) Name and Address of Medical Practitioner / Family Doctor: _____________________
______________________________________________________________________________________________________________________________________________

6) Sum Insured opted for per family under hospitalisation expenses cover and per member of the family under Personal Accident cover:
Rs. 50,000 ( ) Rs.100,000 ( ) Rs.1,50,000( ) Rs.200,000 ( ) Rs.2,50,000( )
Rs.300,000 ( ) Rs.400,000 ( ) Rs.500,000 ( )

7) Details of the persons to be covered (Self + Spouse + 2 Children below 21 years)
(Age: 5 years to 65 years only).
Persons (Self + Spouse + 2 Children below 21 yrs)
Sl.no.
Details 1 2 3 4
i Name

ii Date Of Birth

iii Sex

iv Relationship with
proposer
v Do the persons suffer from :
a. Hypertension Yes / No Yes / No Yes / No Yes / No
b. Diabetes Yes / No Yes / No Yes / No Yes / No
c. Heart Disease
including IHD Yes / No Yes / No Yes / No Yes / No
vi Existing ailments /
diseases, if any.

vii Illness / Injury
sustained in past – give details.

8. Photographs of the insured persons ( Stamp size – 2 each)

Name Name Name Name

9) I have existing Mediclaim Insurance : yes / no.
If yes 1) Name of Insurer :
2) Sum Insured :
(In case of existing mediclaim, settlement will be as per the rules of the Insurance Company).

10) I hereby authorise the Bank to debit my a/c._____________________ for applicable Premium _________________ / OR
Premium Rs.___________________ paid by Cheque No._____________ Date________
Cash Debited to A/c. No.______________________ Date_____________________

Declaration

I hereby declare and warrant that the above statements are true and complete. Myself and Family members are maintaining good health subject to item nos. 7(v) & 7(vi). I have read the salient features of the policy and willing to accept the coverage subject to the terms, conditions and exclusions prescribed by the Insurance Company as per the agreement between Bank of Baroda and National Insurance Company Limited. I understand that in case of any claim under the policy, Bank of Baroda will not undertake any responsibility or will not accept any correspondence and the same have to be pursued with the TPA in case of Hospitalisation Claim. I have read the terms and conditions of the scheme and I shall abide by the same.

Place: ______________
Date: ______________ SIGNATURE OF THE PROPOSER.

FOR OFFICE USE ONLY

Premium paid by _____________ dated _____________ for Rs.____________.

Place: ______________
Date: ______________ SIGNATURE OF THE BRANCH MANAGER

PROHIBITION OF REBATES

(1) No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take 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 or continuing a policy except any rebate as may be allowed in accordance with the published 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.