NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation of India)

Regd. Office : 3, Middleton Street , Calcutta – 700 071

PROPOSAL FORM FOR REVISED MEDICLAIM INSURANCE POLICY

AGENCY CODE : ANNUAL PREMIUM Rs. POLICY No.
DEV. OFFICER CODE :
IMPORTANT
(a) The Company will not be on risk until the Proposal and 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, eligible dependent children parents)
are required to be covered, separate Insured Person Details form should be completed for such
family members.
PROPOSER DETAILS
1. Name of the Proposer :
(surname) (name) FOR OFFICE USE ONLY
2. Address and Telephone No. (I) Residence :
(ii) Office :
3. Total number of members to be covered (in figures) :
(in words) :
4. Period of Insurance : / From :
To : / Midnight
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 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 accept any rebate
except such rebate as may be allowed in accordance with the prospectus or tables of the Insurers.
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.
INSURED PERSON DETAILS
POLCIY NO. :
INSURED PERSON NO. :
ANNUAL PREMIUM :
To be completed separately including Questionnaire form for each Insured Person. (If more than one
Insured Person is 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
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 :
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. and period
Of cover
(b) Claim Amount Received /
Receivable
Period ………………………/ From ……………………………../To
11. Any proposal for this Insurance or
Any other similar Insurance refused
Or higher premium charged if so give
Details
12. MEDICAL HISTORY TO BE
COMPLETED BY THE PROPOSER /
INSURED PERSON
(a) Are you in good health and free from
Physical and mental disease or infirmity
Or medical Complaints ? :
(b) If not in good health give full details :
13. Have you ever suffered from any of the
Disease / illness ? if yes, give details :
(a) Any nervous, mental or psychiatric disease :
(b) Slipped disc or other spinal disorder or
(fainting episode, blackout, fit) paralysis of
any kind :
(c) High blood pressure, heart disease, including
Ischaemic heart disease, other circulatory
Disorders etc. (rheumatic fever) :
(d) Fistula, Piles, Hernia, Varicose veins :
(e) Any disease of the bones or joints including
Rheumatic disease :
(f) Disease of uterus, ovaries or breast or any
Specific gynaecologist 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
Nacessitate 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 disease
(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.
Name if illness / disease injury
And treatment received
Date first
treated
Name of attending medical
pratitioner, surgeon with his
address and Telephone No.
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 option Rs. ¼¼¼¼¼¼¼¼¼¼.
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
questionnaire are incorrect or untrue in any respect, the Insurance Company shall incur no liability under
this Insurance.
I have read the Prospectus and I/am willing to accept the coverage subject to terms, conditions and
exceptions prescribed by the Insurance Company therein.
Signature : ¼¼¼¼¼¼¼¼¼¼¼¼ Date :
Place : ¼¼¼¼¼¼¼¼¼¼.
Name of the Proposer / Insured Person (IN BLOCK LETTERS)¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
N.B. : This should necessarily be signed by insured. In case of minor, guardian or proposer may sign.
FOR OFFICE USE ONLY
Basic Premium for scheme : Rs. ¼¼¼¼ ¼¼¼..
Family Discount : Rs. ¼¼¼¼¼¼¼..
Staff Discount : Rs. ¼¼¼¼¼¼¼..
Annexure ‘A’
TO BE COMPLETED BY PROPOSER IN CASE OF ADVERSE HISTORY 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 antidiabetic drugs ?
If so, please give name with dose :
4. Please give details of Fasting and
Postprandial Blood Sugar readings, E.C.G.
Findings and other investigation reports
With dates, please also send reports :
5. Do you suffer or have suffered from any
Complications of diabetes or any other
Disease ? :
HYPERTENSION QUESTIONNAIRE
1. What your Bloodpressure reading ?
Please state with dates ? :
2. Please state names of antithypertensive
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 QESTIONNAIRE
1. Did you ever suffer from chest pain or
Coronary insufficiency or myocardial
Infarction ? If so, please give diagnosis
And date.
2. Please state the name and dose of drugs
You are taking at present.
3. Please state the findings with dates of
Investigations done like ECG, Stress test,
Coronary angiography, X-ray, Pahtology
Reports etc. Please send reports with the
Proposal form.
4. Please state the date of hospitalisation and
Names of hospitals and consultants.
5. Please state complications and other disease,
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.
Place :
Date : Signature of Proposer
Annexur ‘B’
(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,
Operations, accidents,
Investigations with date, major
Medical complaints of
Hospitalisation :
(c) Details of present and past
Medication with duration :
(d) Is he cured of diseases, if any ?
When was your treatment , If any,
Given , stopped ? :
3. General Examination :
4. Systematic Examination :
Signature of Consulting Physician¼¼¼¼¼¼¼¼¼¼¼¼¼¼..
Signature of Proposer ¼¼¼¼¼¼¼¼..Name of consulting Physician :
Date : Qualifications :
Place : Address :
Telephone Number :
TO BE COMPLETED BY OFFICIAL OF INSURANCE COMPANY
Do you consider the risk acceptable ?
Competent Authority :
Branch Manager :
Divisional manager :