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GST Number
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No Relationship With Proposer Name Gender DOB Occupation Sum Insured Personal Accident Add On SI-Personal Accident Add On Critical illness Add On SI-Critical illness Add On Hospital Cash Add On SI-Hospital Cash Add On Nominee Name Relationship with nominee Premium Remove
1.Has any of the person proposed to be insured ever suffered/or suffering from major medical illness.? *
a. High or low blood pressure, Chest pain, or any other cardiac disorder.
b. Tuberculosis, Asthma, Bronchitis or any other lung/respiratory disorder
c. Ulcer (Stomach/Duodenal), Liver or gall bladder disorder or any other digestive tract disorder.
d. Kidney Failure, Stone in kidney or urinary tract, Prostate disorder or any other kidney/urinary tract disorder.
e. Stroke, Epilepsy (fits), Paralysis or any other nervous system (Brain, Spinal Cord, etc.) disorder.
f. Diabetes, Impaired glucose tolerance (pre-diabetes), Thyroid/Pituitary Disorder or any other endocrine disorder.
g. Tumour (Swelling) benign or malignant, any external ulcer/growth/cyst/mass anywhere in the body.
h. Arthritis, Spondylosis or any other disorder of the muscle/bone/joint.
i. Diseases of the Ear/Nose/Throat/Teeth/Eye (please mention Dioptres in case of refractory error)
j. HIV/AIDS or sexually transmitted diseases or any immune system disorder.
k. Anaemia, Leukaemia, Lymphoma or any other blood/ lymphatic system disorder.
l. Psychiatric/Mental Illnesses or Sleep disorder.
m. Uterine Fibroid, Fibro adenoma breast or any other Gynaecological (Female reproductive system)/Breast disorder.
1.Been addicted to alcohol, narcotics, and habit forming drugs or been under detoxication therapy? *
2.Been under any regular medication (self/prescribed)?
3.Undertaken any lab/blood tests, imaging tests viz. scans/MRI in the last 5 years other than routine health check-up or pre-employment check-up?
4.Undertaken any surgery or a surgery been advised and have surgery still pending?
5.Suffered from any other diseases/illness/accident /injury other than common cold or fever?
Are you covered under any Group Mediclaim Policy?
: | : | : | : | :
No Name Occupation Blood Sugar Levels Blood Pressure Systolic Blood Pressure Diastolic Cholesterol Level Height (ft.) Weight (kg) Body Mass Index Pre-Existing Diseases Tobacco and alcohol Co Morbidity
1.Is any of the member currently pregnant?
2.Any complaint of diabetes, hypertension or any complication during current or earlier pregnancy?
Total Premium to be paid for your complete health insurance is :
(Exclusive of GST)
Annual Income is required.
Basic Premium: (A)

Additional Cover(s) Details
Critical Illness:
Personal Accident:
Hospital Daily Cash:

Total Premium on Additional Covers: (B)

Discount Details: Discount(%)
Sub Limit Discount:
Treatment in Tiered Hospital Discount:
Multiple Members Discount:
Policy Duration Discount:
E-Policy Discount :
Lifestyle Discount :

Total of Discounts: (C)

Net Premium : (A+B-C)
IGST (18%) :
CGST (9%) :
SGST (9%) :
UGST (9%) :
Final Premium :
I have read and understood the Declaration, hereby agree to agreements, terms and conditions mentioned in Declaration.