VARISTHA Mediclaim for Senior Citizens
PROPOSAL FORM

1) Name of the Proposer:_____________________________________________
2) Postal Address and Telephone No._________________________________________

3) Name and Address of Medical Practitioner / Family Doctor :

4) Whether Critical Illness cover is required: Yes/No.

5) Do you opt for additional co-payment: Yes/No

6) Name of the pre-existing disease(s) proposed to be covered:
(On payment of additional premium)
(a) Diabetes
(b) Hypertension
(c )Diabetes and Hypertension

7) Sum Insured per person under:
(a) Hospitalization including Domiciliary Hospitalization: Rs 1,00,000/-

(b) Critical Illness: Rs 2,00,000/-

8) Details of the persons to be covered:

1 2
NAME
Date of birth
Sex
Relationship with the proposer
Do you suffer from hypertension
Do you suffer from Diabetes
Do you suffer from any cardiac ailment
Do you suffer from any other disease / ailment

8) Photographs of the Insured persons: - Please affix two photographs of each
insured person (Stamp size only)
I I II II

Name Name Name Name

9) Have you any existing Mediclaim Insurance : Yes / No.
If yes 1) Name of Insurer :
2) Sum Insured :

(In case of existing mediclaim, settlement will be as per the rules of the Insurance Company).

Declaration

I hereby declare and warrant that the above statements are true and complete. I have read the salient features of the policy and willing to accept the coverage subject to the terms, conditions and exclusions contained in the Prospectus and the Policy.

Place: ______________

Date: ______________ 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 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 a part of commission payable or any rebates of the premium-shown on the policy nor shall any person taking out or renewing or 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.