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

PROPOSAL FORM FOR MEDICLAIM POLICY (2007)

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
communications of acceptance has been given to the proposer in writing on full payment of premium.
B) For 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 check up at a designated
hospital/nursing home. The Divisional Office/Branch Office in the name of hospital/Nursing home will give a
referral slip for conducting the pre-acceptance health check up. The details of the check up to be done are
available with the Divisional Office/Branch Office.
C) If other family members residing with proposer i.e. spouse, eligible dependent children and dependent
parents and dependent parents in law 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.
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: (please Tick)

Professional/Administrative/Managerial

Business /Trader

Clerical, Supervisory and related worker

Hospitality and Support Worker

Production Worker, Skilled and non-Agricultural Labourer

Farmer and Agricultural Worker

Police/Para Military/Defence

Housewife

Retired Person

Student – School and College

Any Other
new.med.prop.form 2
4. Average Monthly Income Rs._______________ Income Tax PAN No:__________
5. NAME, ADDRESS & TEL.NO: OF FAMILY PHYSICIAN_____________________________
_______________________________________________________________________
QUALIFICATION:____________________ REGN .NO: _________________
6. Are you a member of Recognized Health Club/Gymnasium:
If yes, then submit proof of your membership __________________________
7. 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:
Sr.
No.
Content Details
Name of Insurer
Insurance Scheme
Policy No.
Period of cover
Claim Amt. Recd./receivable
8.Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium
charged. If so, give details:
9.DETAILS OF PERSONS TO BE INSURED:
History of
(Pl s. Tick)
Sr.
No
:
Name of all the
persons
Date of
Birth
Sex
(M/F)
Relation (*)
with the
Proposer
Sum
Insured
selected Diab
etes
Hyper
tension
Signature
1
2
3
4
5
6.
(*)Relation as per following table
Self Spouse Father
Mother Son Daughter
Others (please specify)
10. 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)
new.med.prop.form 3
1) Are all the members proposed for insurance in good health and free from physical and Mental disease or
infirmity? If no, give details of the illnesses/ diseases for each member. Select the illness/conditions from
the table given below:
Sr.
No.
Name of the Person Nature of illness/pre-existing diseases (*)
*Table for selecting Pre-Existing Disease (PED)
Ischaemic Heart Disease Hypertension Diabetes Mellitus
Spinal or Vertebral Disorders Cataract Breathing Disorders
Uterine Bleeding Arthritis and Joint disorders Gastritis and Duodenitis
Kidney disorders Headache Syndromes Hernia
Stroke and T.I.A. Thyroid and Other Hormonal
Disorders
E.N.T. Disorders
Cholelithiasis
Any Malignancy Hemorrhoids
Enlargement of Prostate (BPH,
enlargement of prostate)
Any Other (Please specify)
2) 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
the
person
Nature of
illness/disease/injury &
treatment received
(please refer
Date on which first
treatment taken
First treatment
completed/is
continuing
Name of attending
medical
practitioner/surgeon
with his address &
tel. Nos.
new.med.prop.form 4
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.
3) Are there any additional facts affecting the proposed
Insurance, which should be disclosed to insurers? If yes,
then give details below:
4) 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 give details below:
5) Where do you wish to take treatment? : Zone I (Mumbai)
Zone II (Delhi/Bangalore)
Zone III (Rest of India)
6) Name of the Assignee- Relationship
7) Period of Insurance: From____________ To _______________
8) Declaration: I declare that the persons proposed for insurance are my family members and they are not engaged in
high risk occupation. I also declare that none of them suffer from any pre-existing conditions and that I have given
explicit information of such sickness/disease/injury sustained in the above columns where the information has been
sought. 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 the basis of the contract should the insurance be
affected. If after the insurance is affected, 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.
Photographs of Insured Persons:
Signature of the Proposer:__________________ Date: __________/_________/_________
DD MM YY
Place:______________
Propo
ser
2 3 4 5
Propo
ser
1 2 3 4 5
1
new.med.prop.form 5
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.
FOR OFFICE USE ONLY:
Sr.
No
.
Name of
insured
person
Date of
Birth
/Age
Sex
M/F
Relation Occupa
-tion
S.I.
(Rs.)
CB
%
Premium Loading
for
diabetes
and
hyperten
sion
Loading for
high claim
ratio
1
2
3
4
5
6
Total:
Loyalty Discount
Family Discount 10%
Service Tax
Remarks of Underwriter:
Gross Total