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

PROPOSAL FORM FOR HEALTH INSURANCE POLICY (2010)

Platinum/ Gold/ Senior Citizens
Please read the prospectus before filling up this form.
A) The company shall not be on risk until the proposal has been accepted by the Company and
communication of acceptance has been given to the proposer in writing on full payment of premium.
B) Persons above 45 years of age will have to undergo, pre-acceptance health check up as detailed in the
prospectus.
C) If other family members residing with proposer i.e., spouse, eligible dependent children and dependent
parents are required to be covered, complete details of each person should be furnished. Two stamp size
photograph of each person are to be submitted, one of which is to be affixed on the proposal.
D) Fresh proposal form is required along with pre acceptance medical check up as mentioned in item (B)
above, irrespective of age, when there is break in insurance cover or when there is request for
enhancement in the sum insured of Rs one lac and above.
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.
1. NAME OF PROPOSER : Mr/Mrs. _______________________________________________________
2. RESIDENTIAL ADDRESS: ____________________________________________________________
Tel. No: Fax No: E-Mail: _________________________
3. Occupation:
4. Average Monthly Income Rs.
5. NAME, ADDRESS & TEL. NO. OF FAMILY PHYSICIAN ___________________________________
____________________________________________________________________________________
QUALIFICATION: ______________________ REGN. NO.: __________________________________
6. Are you at present or have you been at any other time in the past covered under any other Insurance (PA,
Cancer Insurance, Hospitalization Insurance or other Medical Insurance). If so, give particulars of:
1. Name of Insurer
2. Policy No.
3. Period of cover
4. Claim Amt. Recd./receivable
7. Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium
charged. If so, give details:
8. DETAILS OF PERSONS TO BE INSURED:
Sr.
No.
Name of all
the Persons
Date of
Birth
Age Sex
(M/F)
Relation
with the
Proposer
Sum
Insured
Selected
Signature Nominee Nominee
relationship
1
2
3
4
5
1
6
9. MEDICAL HISTORY: Please answer the following questions with Yes or No (A dash is not sufficient
and give full details in respect of all the persons to be insured)
1 2 3 4 5 6
1) Are you in good health and free from physical and
Mental disease or infirmity?
2) Have you ever suffered from any illness or disease
upto the date of making this proposal?
3) Do you have any physical defect or deformity?
4) Have you ever been admitted to any hospital/
nursing home/clinic for treatment or observation?
5) Has any of the persons proposed for insurance
has suffered from any illness/disease or had an
accident in the past? If so, give details as under:
Name of
person
Nature of illness/disease/
Injury & treatment received
Date on which
first treatment
taken
First Treatment
completed/is
continuing
Name of attending medical
practitioner/surgeon with
his address & Tel. Nos.
Note: This information should be given for any of the persons proposed for insurance, if he/she had suffered
from any illness/disease injury, please give details separately.
6) Are there any additional facts affecting the proposed
Insurance, which should be disclosed to insurers? If yes,
then give details below:
7) Please give details of any knowledge or any positive
existence or presence of any ailment, sickness or
injury, which may require medical attention? If yes,
then furnish details below:
Name of illness / injury First diagnosed Treatment taken
8) Are you suffering from any of the following conditions?
Hypertension / Diabetes/ high cholestrol
9) Do you require TPA Services
(If “No”, claim will be settled on reimbursement
basis only, and No reduction in Premium.)
10) Name of the Assignee - ___________________________ Relationship _______________________
11) Period of Insurance: From ________________________ To _______________________________
12) Declaration: I declare that the persons proposed for insurance are my family members. I also declare
that I have given explicit information on any Pre-Existing sickness/disease/injury sustained. I further
declare that the above statements in respect of myself and my family members, are true and complete. I
consent and authorize the insurers to seek medical information from any Hospital/Medical Practitioner
who has at any time attended me or my family members or may attend concerning any disease or illness
which affects my or my family members, physical or mental health. I agree that this proposal shall form
2
YES NO
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.
Signature of the Proposer : Date : ____ / ____ / _______
DD MM YY
Place:
Photographs of Insured Persons:
Section 41 of Insurance Act, 1938
PROHIBITION OF REBATES
1) No person shall 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.
Remarks of Underwriter:
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Proposer 1 2 3 4 5
Proposer 1 2 3 4 5