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Personal Details
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Policy Details
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1 Year
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Personal Details
Title
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Mr.
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Proposer Name
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Date of Birth
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Gender
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Email Id
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Std No
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ID Type
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PAN No.
Aadhaar Card No.
OTH Other Detail
ID No
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Do you have EIA No.
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EIA No.
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E-KYC Information
Get your document signed digitally ?
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Contact Details
Location
Pin Code
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Address Line 1
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Address Line 2
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GST Details
Inward Credit For GST Number?
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GST Number
GST Number is required.
Proposal Details
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{{t.PolicyType}}
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{{t.PlanType}}
Sub Category
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{{t.Covers}}
No of Members
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Please Specify Treatment only in tiered hospitals
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Family Details
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{{t.FamilyCom}}
Sum Insured for family
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{{t.SumInsured}}
Member Details
Relationship with Proposer
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{{t.FamilyCom}}
Member Name
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Date of Birth
Occupation
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{{t.SumInsured}}
Nominee Name
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{{t.FamilyCom}}
Personal Accident Add On
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No
Yes
SI-Personal Accident Add On
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{{t.SumInsured}}
Critical illness Add On
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No
Yes
SI-Critical illness Add On
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{{t.SumInsured}}
Hospital Cash Add On
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Yes
SI-Hospital Cash Add On
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{{t.SumInsured}}
No
Relationship With Proposer
Name
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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
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We need to mention- In consideration of all the member insured under the policy
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.
Yes
No
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.
Lifestyle Information
1.Been addicted to alcohol, narcotics, and habit forming drugs or been under detoxication therapy? *
Yes
No
2.Been under any regular medication (self/prescribed)?
Yes
No
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?
Yes
No
4.Undertaken any surgery or a surgery been advised and have surgery still pending?
Yes
No
5.Suffered from any other diseases/illness/accident /injury other than common cold or fever?
Yes
No
Are you covered under any Group Mediclaim Policy?
Yes
No
Member Details
Blood Sugar Levels
:
70 mg - 99 mg
|
Blood Pressure Systolic
:
90 - 130
|
Blood Pressure Diastolic
:
60 - 80
|
Cholesterol Level
:
150 - 200
|
Body Mass Index
:
17.5-24.9
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
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Yes
No
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Yes
No
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Yes
No
Pregnancy Details
1.Is any of the member currently pregnant?
Yes
No
2.Any complaint of diabetes, hypertension or any complication during current or earlier pregnancy?
Yes
No
Total Premium to be paid for your complete health insurance is :
(Exclusive of GST)
Income and Occupation Details
Proposer Occupation
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{{t.Occupation}}
Annual Income(Rs)
Annual Income is required.
Summary
Quotation No.
Quotation Date
Proposer Name
Policy Start Date
Policy End Date
Policy Type
Family Composition
Premium Summary
Basic Premium: (A)
Additional Cover(s) Details
Critical Illness:
Personal Accident:
Hospital Daily Cash:
Total Premium on Additional Covers: (B)
Discount Details: Discount(%)
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.
Payment.
