. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 1 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
PROPOSAL FORM (NIA/Health/20-21/AJ)
Name of the Intermediary:
Mobile Number:
Intermediary Code:
Email ID:
Arogya Sanjeevani, New India Assurance Co. Ltd
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.
Complete details of each person to be covered should be furnished. Two Stamp size photograph of each person are to be submitted, one of which is to be affixed on the proposal.
Note: Loading of 5% on the premium is applicable if any of the proposed member is having Hypertension, Diabetes or BMI>32
Non-disclosure of facts material to the assessment of the risk, providing misleading information, and/or misrepresentation, fraud or non-co-operation by the insured will nullify the cover under the
policy.
1. Proposer’s Details
Name of the Proposer
(As per the Id Card)
Date of Birth:
Gender (M/F/T)
Male/Female/Third Gender
Educational Qualifications
Residential Address
(Permanent )
Landmark/Area/City/Town:
District: State:
Pin:
Address for Correspondence
Landmark/Area/City/Town:
District: State:
Pin:
Email Id
Occupation
Landline/Mobile Number
Family Income
Nature of Id
PAN Card/Voter Id/Passport/Any other
Id Card No
PAN Card No
GST No (If applicable)
Assignee/Nominee Name
Relationship with
Assignee/Nominee
DoB of Assignee/Nominee
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 2 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
2. Details of persons to be Insured and type of Policy:
Sum Insured: Separate proposal form is required if members of the same family are opting for Individual and Floater Sum Insured’s. 1 Proposer, 1 Spouse, 2 Parents, 2 Parents in Law and 4 Children
are allowed.
a) Individual Sum Insured: Maximum 10 members can be covered under the policy
b) Floater Sum Insured: Minimum 2 and Maximum 10 members can be covered under the policy.
Details
Name of the Person
DoB
Gender
(M/F/T)
Sum Insured
Hypertension
Diabetes
Height
(in mtr)
Weight
(in KG)
BMI
(KG/m^2)
Relation with
the Policyholder
Occupation
Individual
Floater
Member 1
Yes/No
Yes/No
Member 2
Yes/No
Yes/No
Member 3
Yes/No
Yes/No
Member 4
Yes/No
Yes/No
Member 5
Yes/No
Yes/No
Member 6
Yes/No
Yes/No
Member 7
Yes/No
Yes/No
Member 8
Yes/No
Yes/No
Member 9
Yes/No
Yes/No
Member 10
Yes/No
Yes/No
3. 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)
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 3 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
a) 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:
S No
Name of the Person
Nature of illness/pre-existing diseases (*)
S No
Name of the Person
Nature of illness/pre-existing diseases (*)
Member 1
Member 6
Member 2
Member 7
Member 3
Member 8
Member 4
Member 9
Member 5
Member 10
*Table for selecting Pre-Existing Disease (PED)
Breathing Disorder
Hernia
Spinal or Vertebral Disorders
Cataract
Hypertension
Stroke and T.I.A.
Cholelithiasis
Arthritis and Joint Disorder
Thyroid and Other Hormonal Disorders
E.N.T. Disorder
Kidney Disorder
Uterine Bleeding
Gastritis and Duodenitis
Any Malignancy
Hypertension and Diabetes
Headache Syndrome
Diabetes Mellitus
Hb1AC<7
Ischemic Heart Disease
Enlargement of Prostate
Any other (Please specify)
Haemorrhoids
4. Are there any additional facts affecting the proposed Insurance, which should be disclosed to insurer? If yes, then give details below:
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 4 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
5. Does any of the proposed members for Insurance are suffering from any of the below mentioned Illnesses or Diseases?
Illnesses /
Diseases
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Member 10
Sarcoidosis
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Malignant
Neoplasms
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Epilepsy
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Heart Ailments
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Cerebrovascular
Disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Inflammatory
Bowel Disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Chronic Liver
Disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Pancreatic
Diseases
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Chronic Kidney
Disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Hepatitis B
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Alzheimer's
disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Demyelinating
disease
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
HIV & AIDS
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Loss of Hearing
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Papulosquamous
disorder
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Avascular
Necrosis
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
6. Has any application or proposal for life, health, accident or critical illness including renewal and reinstatement ever been declined, deferred, withdrawn or accepted at special rates or terms by
The New India Assurance Co. Ltd or any other insurance company. (Yes/No) If Yes, give details:
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 5 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
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), either by us or
by any other Insurer. If so, give particulars of:
S. No
Insured Name.
Policy No. / Proposal No
Period of Insurance
Sum Insured
Claims lodged during
policy period (Yes/No)
If Yes, Ailment for
which Claim was
made
1
From
To
2
3
4
5
6
7
8
9
10
8. Proposed Period of Insurance: From ____________________ to ____________________
9. Mode of Premium Payment (Annual/Half-Yearly/Quarterly/Monthly):
10. Important:
a) The information that you give to us on this proposal form or in any supplementary Information form or documentation supplied by you or on your behalf will influence our decision to offer
insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have communicated to us. It is therefore important that your answer is complete and
accurate in all respect.
b) The question in this proposal are indicative rather than exhaustive. You must provide us with all information relevant to the risk to be insured, even if it is not the subject of a question in
this proposal. If you are in any doubt as to what information should be given, you should liaise with your Agent/Insurance advisor/ Insurance Company.
c) The list of exclusions/ inclusions and other policy details are indicative, for complete list and comprehensive details kindly refer policy wordings.
d) The Policy shall become voidable at the option of the Company, in the event of any untrue or incorrect statement, misrepresentation, non- description or non-disclosure of material
particulars in the Proposal Form/personal statement, declaration and connected documents, or any material fact* information has been withheld by beneficiary or anyone acting on
beneficiary's behalf to obtain insurance.
*A material fact will mean and include all important, essential and relevant information, pertaining to the questions made in this proposal form, that are likely to influence company's acceptance
or assessment of the proposal.
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 6 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
11. Proposer Declaration: I declare that the persons proposed for insurance are my family members and I also declare that
(STRIKE OUT ONE OF THESE TWO STATEMENTS THAT IS NOT APPLICABLE)
i. None of them suffer from any pre-existing conditions
YES
NO
ii. I consent for the loading of Premium by 5% for each condition, in case any of the proposed member is suffering
from Hypertension/Diabetes or having BMI>32
YES
NO
iii. I have given explicit information of such sickness/disease/injury sustained in the above columns where the
information has been sought.
i.
YES
NO
a) “I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all
respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.
b) I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company and that the
policy will come into force only after full receipt of the premium chargeable.
c) I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but
before communication of the risk acceptance by the company.
d) I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at any time has attended on the life to be insured/proposer or from any past
or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any insurance company to which an
application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
e) I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with
any Governmental and/or Regulatory authority.”
Signature of Proposer _______________ Date: __________/_________/_________ Place: __________________________
Photographs of Insured Persons:
Photo
Photo
Photo
Photo
Photo
Photo
Photo
Photo
Photo
Photo
Insured 1
Insured 2
Insured 3
Insured 4
Insured 5
Insured 6
Insured 7
Insured 8
Insured 9
Insured 10
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
12. STATUTORY WARNING
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 7 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
Section 41 of Insurance Act, 1938(Prohibition of Rebates) 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 or 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 in the policy, nor shall
any person taking out of renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or table of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakh rupees.
13. Agent Declaration: I,__________________________ in my capacity as an Agent/ Insurance Advisor/ Specified Person of the Corporate Agent/ Authorized employee of the Broker/Relationship
Officer, do hereby declare that I have explained all the contents of this Proposal Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s),
information and response(s) submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of the Contract of Insurance between the
Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy.
I have further explained that if any untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to
be furnished, the Company shall have the right to cancel the policy at its discretion. Further, this declaration does not confirm issuance of policy or assumption of risk thereof.
Name of the Agent: Date: Place
Agent Code:
Signature of the Agent
14. FOR OFFICE USE ONLY:
S No
Name of the Person
Gross Premium
S No
Name of the Person
Gross Premium
Member 1
Member 6
Member 2
Member 7
Member 3
Member 8
Member 4
Member 9
Member 5
Member 10
Remarks of the underwriter :
Total Gross Premium
GST
Net Premium (Including GST)
. THE NEW INDIA ASSURANCE CO. LTD.
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001
NIAHLIP20165V011920 Page 8 of 8
AROGYA SANJEEVANI, THE NEW INDIA ASSURANCE CO. LTD
CHOICE OF TPA.
Third Party Administrator (TPA) means a Company registered with the IRDAI, and engaged by Us for providing health services.
The following TPAs are allotted for servicing your Policy.
1. Assigned TPA:
2. Optional TPA:
If you wish to change your Assigned TPA to Optional TPA, please sign the below declaration and submit it to the Operating Office.
I wish to change my Asigned TPA to Optional TPA i.e. to ----------------------------
Signature of the Proposer. Date
Recommended by the Office In-charge:
Name:
Date:
DO/BO/MO:
Seal:
