The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

UNIVERSAL HEALTH INSURANCE POLICY
PROPOSAL FORM

IMPORTANT
a) The Company will not be on risk until the proposal and Insured Person 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 and dependent parents required to be covered, separate Insured Person details forms should be completed for each of such family members.
c) In case any family is identified as BPL family, a certificate as proof thereof issued by an official not below the rank of B.D.O./ Tehsildar of Revenue Dept. of the concerned State Government has to be attached.
d) Non-disclosure of facts material to the assessment of the risk or providing misleading information will nullify the cover under the policy issued.
1. Name of the Proposer :

2. Address :

3. DETAILS OF THE PERSONS TO BE INSURED :
Name of Insured Person Age Sex Indicate
Whether
Earning Head of Family Relationship with the Insur-ed Details of pre-existing diseases/
illness Name of nominee
(Only applicable to Head of family) Whether belonging to below poverty line (BPL) Group
1.
2.
3.
4.
5.
6.
7.
Note : Please attach additional sheets for covering each family as per the above format.
4. Period of Insurance : From____________ To_____________
I/We, hereby declare that the details/information furnished above are true to the best of my knowledge and belief.

Date : Place : Signature of the proposer
PROHIBITION OF REBATES
(1) No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take our 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.
DEV. OFFICER / AGENCY CODE ANNUAL PREMIUM POLICY NO.
Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. Insurance is the subject matter of solicitation.