National Insurance Company Limited
Regd.Office 3,Middleton Street,Kolkata – 700 071

STAR NATIONAL SWASTHYA BIMA

PROPOSAL FORM

1. Name of the Bank Branch_________________________ Branch Code No________________

2. Name of the Customer____________________________________

3. Type of Account(SB/CA/FDR/Any other Pl. tick) and Account Number

4. PAN No.(if any)--------------------------------------

5. Postal Address & Telephone No.___________________________
Pin Code – ________________

6. Name and Address of the Medical Practitioner & Family Doctor(if any)
__________________________________________________________
__________________________________________________________

7. Period of Insurance: From___________ to ____________
(Policy is valid for 1 year from the date of commencement)

8. Sum Insured per Family:
Floater Sum Insured (Rs.) Premium including Service Tax at 12.24% (Rs.) Tick your choice
50,000 930/-
1.0 lac 1746/-
1.5 Lac 2,635/-
2.0 lacs 3390/-
2.5 Lacs 4,059/-
3.0 lacs 4729/-
4.0 lacs 5899/-
5.0 lacs 7071/-

Note: Premium amount is same irrespective of number of members joining the policy i.e. either the policy is taken for 1+1 or 1+2 or 1+3 or even one member only

9. Details of Persons to be covered:

Sr No Name of the insured person Age M/F Relationship Existing Disease/ illness/injury Treatment received for the last 3 years*
1 A/c Holder

2 Spouse

3 Child – 1

4 Child – 2

*Details may be given in a separate sheet, if space is not sufficient.

Photographs of the insured Persons:
Account Holder Spouse Child – 1 Child - 2

D.O.B. D.O.B. D.O.B. D.O.B.

(D.O.B. - Date of birth)

1. I have existing Medical insurance: Yes / No
If Yes –
(i) Name of Insurer _______________
(ii) Policy No. _________________
(iii) Period of Ins. ________________
(iv) Sum insured ____________________________
(In case of existing Mediclaim, settlement will be as per rules of the insurance company.)

12. I, hereby authorise the Bank to debit my account for applicable premium and pay the same to National Insurance Co. Ltd.

I hereby declare and warrant that the above statements are true and complete. Myself and family members are maintaining good health subject to item no 9. I have read the salient features of the policy mentioned in the prospectus and willing to accept the coverage subject to the terms, conditions, definitions and exclusions prescribed by the insurance company as per the Agreement between Bank of India and National Insurance Co. Ltd. I understand that in case of any claim under the policy, Bank of India will not undertake any responsibility or will not accept any correspondence and the same have to be pursued with the insurance company / TPA only.

I have read the terms and conditions of the scheme and I shall abide by the same.

Place:

Date: Signature of the Proposer
_______________________________________________________________________

The Manager
Bank of India
_______________ Branch.

My/Our SB/CD/TD Account No.

I/We hereby authorise you to debit my/our account with Rs._______(Rupees ________________________) towards premium for the STAR NATIONAL SWASTHYA BIMA policy and pay the same to National Insurance Company Limited.

I/We am/are aware that Bank of India is only a facilitator and bringing Star National Swasthya Bima Policy for my/our benefit. I am also aware that I will be receiving the policy directly from National Insurance Company Ltd. I/We understand that in case of any claim under the policy, Bank of India will not undertake any responsibility or will not accept any correspondence and the same have to be persuade with the Insurance Company/Third Party Administrator only.

Place :

Date : Signature of Account Holder/s