UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014
DIVISIONAL / BRANCH OFFICE.............................................

FAMILY 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 above 45 years of age or persons below 45 years of age, having adverse medical
history declared in the proposal form, will have to undergo pre-acceptance health checkup
at a recognised Hospital/Nursing Home/Laboratories/Clinic at the cost of insured.
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.
PROPOSER DETAILS
1. Name of the proposer ………………………. ………………………….
(Surname) (Name)
2. Address and i) Residence :
Telephone No
ii) Office :
3. Total number of members to be covered (in figures):
(in words):
(Separate Insured Person Details forms are to be enclosed)
4. Sum Insured Opted :
5. Do you wish to avail of the following additional covers under the policy:
A. AMBULANCE CHARGES:
B. HOSPITAL DAILY CASH
If yes, for Rs.250/- per day / Rs.500/- per day
6. Period of Insurance From
To (midnight)
SPECIMEN SIGNATURE TABLE
S.No Name of Insured Person Age Sex Relation Signature
1
2
3
4
5
Photographs of Insured persons:
Photograph
Photograph Photograph Photograph Photograph Photograph
PLACE:
DATE: Signature of the proposer
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 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.
(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.
UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014
INSURED PERSON DETAILS
POLICY NO:
INSURED PERSON No.
ANNUAL PREMIUM
To be completed separately including Questionnaire form for each insured person ( if more
than one insured person required to be covered please obtain additional forms from the
company).
1. Name of the Insured Person :
2. Address :
PIN CODE
State / U.Territory
3. Sex ( Strike out whichever is not
not applicable) : Male / Female
4. Relationship with the proposer :
5. Date of Birth and Age :
6. (a) Average Monthly Income : Rs.
(b) Income Tax PAN No. :
7. Profession / Occupation / Trade or
Business (Please describe fully
With nature of duties ) :
8. Name and address of the Medical
Practitioner, his qualifications
& Telephone No. if any. :
Pincode
Tel. No.
9. Medical Practitioner's Regn. No. :
10. Are you at present or any other time in the past covered
Under any other Insurance
Type (PA, Cancer Insurance, Hospitalisation Insurance
Or other Medical Insurance), If so,
Give particulars of :-
(A) Insurer Policy No. Period of cover
(B) If current insurer is United India:
Please specify;
(i) Policy Type Policy No. Office Expiry Date
(ii) Date of first coverage with United India which has since been renewed continuously
without break or within grace period
w.e.f ______________ under Policy No._________________________________
and Endorsement No._____________________________
(C) Claim amounts received / receivable in preceding two years
Amount (Rs.) Illness Policy Period Insurer Office
(a) Insurer, Policy No. and
Period of cover :
(b) Claim Amt. Recd. / Receivable :
Period : From: TO:
11. Any Proposal for this Insurance or any other similar insurance refused
Or cancelled or higher premium charged. If so give details:
12. MEDICAL HISTORY TO BE COMPLETED BY
THE PROPOSER / INSURED PERSON
PLEASE ANSWER THE FOLLOWING QUESTIONS IN
YES OR NO. ( A DASH IS NOT SUFFICIENT )
AND GIVE FULL DETAILS IF ANSWER IS YES.
12.1 Are you in good health and free from
Physical and mental diseases or infirmity
Or medical complaints?
12.2 If not in good health give full details
13. Have you ever suffered from any of the diseases / illness?
If yes, give details :
(a) any nervous, mental or psychiatric disease
(b) slipped disc or other spinal disorder
(fainting episode, blackout, fit ) paralysis of
any kind
(c) high blood pressure, heart diseases, including ischaemic
heart disease, other circulatory disorder etc.,
(rheumatic fever)
(d) Fistula, Piles, hernia, varicose veins
(e) Any disease of the bones or joints
Including rheumatic disease
(f) diseases of uterus, ovaries or breast or
any specific gynaecological disorders
(g) any respiratory or allergic disease
(h) any disorder of the stomach, ulcer, bowel or
gall bladder, kidney stones etc.,
(i) any cancer, malignant growth, boil, cyst or wound
etc., which does not heal or improve despite
treatment
(j) any other complaint requiring specialist's consultation
or surgical or hospital treatment or investigations
(k) any complaint or tendency that may necessitate such
consultation or treatment in the future
(l) any dimness of vision / cataract
(m) any disease of ears or difficulty or
interference with hearing
(n) diabetes or any urinary diseases
(o) any other illness or disease or accident or
operation sustained by you.
14. (a) Have you ever suffered from dental
problems ? Yes / No
(b) If yes specify same
(c) When were you treated last for same
15. Give particulars in table below of any other illness or disease or accident or operation
sustained by you in the past
S.N. Nature of illness /
disease injury and
treatment received
Date first
treated
Name of attending medical
practitioner, surgeon with his
address and Telephone
Number
Whether fully
cured
1.
2.
3.
4.
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.
18. Please specify sum Insured opted: Rs.
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 my
physical or mental health. 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: -----------------------
NAME OF THE PROPOSER / INSURED PERSON -----------------------------------------
( IN BLOCK LETTERS )
N.B: This should necessarily be signed by insured person. In case of minor, guardian or
proposer may sign.
## FOR OFFICE USE ##
Basic Premium for Scheme … Rs. . . . . . . . . . . . . . .
Premium for Additional covers opted Rs. ………………………………
Staff Discount … Rs. . . . . . . . . . . . . .
TO BE COMPLETED BY PROPOSER IN CASE OF ADVERSE HISOTRY
IN THE PROPOSAL FORM IN RESPECT OF APPLICABLE ILLNESS:
DIABETES QUESTIONNAIRE:
1. Date of diagnosis of Diabetes
2. Did you suffer from coma or procoma ?
3. Do you take any anti diabetic drugs ? If so please
give names with dose.
4. Please give details of Fasting and post prandial
Blood Sugar readings, E.C.G. findings and other
investigation reports with dates. Please also
attach reports
5. Do you suffer or have you suffered from any
complications of diabetes or any other diseases?
HYPERTENSION QUESTIONNAIRE
1. What is your Blood Pressure reading, please state
with dates?
2. Please state name of antihypentensive drugs
with dose
3. Are you a smoker?
4. Is it essential / secondary / Malignant
Hypertension?
5. Please state whether you have suffered from any
complications or other diseases
6. Please give findings of all investigation reports
CHEST PAIN OR CORONARY INSUFFICIENCY
OR MYOCARDIAL INFARCTION QUESTIONNAIRE:
1. Did you ever suffer from chest pain or coronary
insufficiency or myocardial infarction ? If so give
please give diagnosis and date
2. Please state name and doss of drugs you are
taking at present
3. Please state the findings with dates of
investigations done like ECG, stress test, coronary
angiography’s X-ray, pathology reports etc.,
Please send reports with the prescribed form.
4. Please state the date of hospitalisation and names
of hospitals and consults
5. Please state complications and other diseases if
suffered
6. Please state whether you can do your regular
work and whether you have any limitation of
activity ?
7. Are you advised any special treatment? If so
please give information
Signature of Proposer/Insured person
PLACE :
DATE:
TO BE COMPLETED BY CONSULTING PHYSICIAN / SURGEON
(in case of adverse Medical History)
1. Name of the Insured:
2. HISTORY
a) Present complaints and investigation if any
b) Any past history of disease, operation,
accidents investigations with date, major medical complaints or hospitalisation
c) Details of present and past medication with duration
d) Is he cured of disease, if any? When, was your treatment, if any, given, stopped?
3. General Examination
4. Systematic Examination
5. Do you consider the risk acceptable
Signature of proposer Signature of consulting physician
Name of consulting Physician:
Qualifications:
Address:
Place:
Date: Telephone Number:
TO BE COMPLETED BY OFFICIAL OF INSURANCE COMPANY ---------------------
DO YOU CONSIDER THE RISK ACCEPTABLE?
COMPETENT AUTHORITY