PROPOSAL FORM
National Mediclaim Policy
Proposal for New Policy Renewal (with change in details) FOR OFFICE USE ONLY
Policy Period: From To midnight of Premium (before discounts) :INR _______________
DD MM YY DD MM YY Net Premium :INR ______________
Instalment Premium :1st - INR ___________
IMPORTANT INSTRUCTIONS 2nd installment or more – INR ___________
(a) This Proposal Form shall be the basis of the policy to be issued. It is
therefore essential that all the information sought in this Proposal Intermediary_____________________________________
Form and all additional information relevant to the risk to be Code__________________ Date_______/____/_________
insured is provided fully & accurately. Please do not leave any space
Dev. Officer _____________________________________
blank, or put dashes.
(b) The Company will not be on risk until the Proposal have been Code__________________ Date_______/____/_________
accepted by the company and communication of the acceptance has
been given to the proposer in writing after full payment of premium. Risk acceptable: Y/ N
(c) Details of the proposer and up to 5 insured persons can be filled in Competent Authority:
this Proposal Form. One stamp size photograph of each person are Name ______________________________
to be affixed on the Proposal Form. If required, additional forms to Designation: ___________
be attached. Signature_______________
(d) Portability Form is provided in Annexure B. Policy No. _________________________________
(e) List of documents required is provided in Annexure C. Issuing Office: _______________________________
Office code: ______________
1. PROPOSER / INSURED DETAILS: Mr. Ms. Mrs.
Name: _______________________________________________________________________________________________________________
Occupation/Business/Service/Other: ________________________________________________ PAN No: _____________________________
Aadhaar No: __________________________________________ ABHA ID: _____________________________________
2. ADDRESS / CONTACT DETAILS:
Mobile No: _________________________________Email ID: __________________________________________________________________
Present Address:______________________________________________________________________________________________________
__________________________________ District: _______________________________State:______________________Pin:______________
Permanent Address:___________________________________________________________________________________________________
__________________________________ District: _______________________________State:______________________Pin:______________
3. NOMINEE DETAILS: (use separate form for another nominee)
Name of Nominee: _____________________________________________________________________Date of Birth: dd / mm / yyyy
Relationship with proposer ____________PAN no: _________________Mobile: ____________________Email ID: ______________________
Name of Guardian (if nominee is minor) __________________________________Percentage of claim amount payable: ___________
Present Address:______________________________________________________________________________________________________
__________________________________ District: _______________________________State:______________________Pin:______________
Permanent Address:___________________________________________________________________________________________________
__________________________________ District: _______________________________State:______________________Pin:______________
4. POLICY DETAILS: (Please strike through the one not required)
Is TPA service required?: Yes No Is Co-payment opted?: 20% 15% NO
Premium payment frequency: Annual Half Yearly Quarterly
5. BANK DETAILS:
Name in Bank Account: ______________________________________________________________________________________________
Bank: __________________________________________________________________________Branch: _____________________________
SB Account No: __________________________________________________ IFSC: _____________________________________________
6. INSURED PERSON DETAILS
No. of persons covered (including proposer) _________ (in figure), __________________________ (in words)
Paste one stamp sized photographs and sign below
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 1 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
Proposer Insured Person Insured Person Insured Person Insured Person Insured Person
All the fields are mandatory. Please do not leave any field blank.
Customer Code
Proposer Insured Insured Insured Insured Insured
Person 1 Person 2 Person 3 Person 4 Person 5
Name
Date of Birth
(mm/dd/yyyy)
Age *
Gender (M/F)
Height (cm)
Weight (kg)
Blood Group
Marital Status
Relationship with
Proposer
Dependent (Y/N)
Occupation
Do you smoke? (Y/N)
Do you drink alcohol?
(Y/N)
Basic Sum Insured #
Covid 19 Vaccination
Doses taken?
(certificate to be
provided)
* For age 50 years and above, please complete Annexure A
# Basic SI available are INR 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 L per Individual
7. INSURANCE PARTICULARS
Is there another Policy covering any/ all of the insured persons for hospitalisation? Yes/ No
If yes, please give details below and attach policy copies
Policy No. Insurer Floater/ Members covered with SI Policy Expiry Last Claimed Porting?
Ind and CB Name Date Claimed Amount (Y/ N) #
Date
# If Yes, please complete Annexure B
8. EXISTING DISEASES OF PROPOSER AND INSURED PERSON
If Proposer/ any Insured Person is/ are diagnosed with any condition, ailment, injury or disease by a physician any time prior to the date
of Proposal or for which medical advice or treatment was recommended by, received from or is being received from a physician,
complete the following table with date of diagnosis. Please do not leave the spaces blank.
Pre Existing Diseases
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 2 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
Insured Insured Insured Insured Insured
Disease Name Proposer
Person 1 Person 2 Person 3 Person 4 Person 5
Diabetes
Hypertension
Cardiac Ailment
Sarcoidosis
Malignant Neoplasms
Epilepsy
Heart Ailment, Congenital heart disease and
valvular heart disease
Cerebrovascular disease (Stroke)
Inflammatory Bowel Diseases
Chronic Liver diseases
Pancreatic diseases
Chronic Kidney disease
Hepatitis B
Alzheimer's Disease, Parkinson's Disease
Demyelinating disease
HIV & AIDS
Loss of Hearing
Papulosquamous disorder of the skin
Avascular necrosis (osteonecrosis)
Any other diseases?
Above PEDs will be covered after a waiting period of 3 years from inception of Policy.
9. PAYMENT DETAILS
Premium Paid by: Cash Cheque DD Others, specify
Amount__________________ Date_____/_____/__________Bank Name
10. DECLARATIONS
I hereby declare and warrant that the above statements are true and complete. I consent and authorize the Insurers to 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.
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 policy and that the policy will come into force only after receipt of the premium chargeable.
I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the proposer after the
proposal has been submitted but before communication of the risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has
attended on the proposer or from any past or present employer concerning anything which affects the physical or mental health of
the proposer and seeking information from any insurance company to which an application for insurance on the proposer has been
made for the purpose of underwriting the proposal and/or claim settlement.
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.
Place: ______________________ ____________________________________
Date: ______________________ Signature of the proposer
CERTIFICATE FROM PROPOSER
The proposal form is filled up by my representative, but the contents of the documents have been fully explained to me and I am
willing to accept the coverage subject to terms, conditions and exceptions prescribed by the Insurance Company therein.
Place : _______________________ ______________________________
Date : ______/_______/__________ Signature
Name of the Proposer (in BLOCK LETTERS) _________________________________________________________
N.B. : This should necessarily be signed by proposer, or by his/her representative if Proposer is a person with disability.
11. SECTION 41 OF INSURANCE ACT, 1938 – PROHIBITION OF REBATES (Amended as per The Insurance
Laws (Amendment) Act, 2015)
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 insurance in respect of 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 on the policy nor shall any person taking out or renewing or
continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the
Insurers.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten
lakh rupees.
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 3 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
National Insurance Company Limited,
Regd. & Head Office: Premises No. 18-0374, Plot no.
CBD-81, New Town, Kolkata – 700156
CIN U10200WB1906GOI001713
Annexure A
MEDICAL EXAMINATION REPORT PERSONAL HISTORY
To be completed by consulting physician / surgeon in case of adverse medical history
1 Name of the Insured Person
:
2 History
(a) Present complaints and investigation, if any
:
(b) Any past history of disease, operations, accidents,
investigations with date, major medical complaints of :
hospitalisation?
(c) Details of present and past medication with duration
:
(d) Is he cured of diseases, if any?
:
When was your treatment, if any, given, stopped?
:
3 General examination
:
4 Systematic examination
:
Name of Medical Examiner & qualification:
Regd.No:
Address: Signature of Medical Examiner:
Date: Signature of Proposer:
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 4 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
Annexure B
Policy No. :
Name of Insured Person :
To be completed by the insured in case of porting from a health insurance policy issued by another insurance company
Portability Form
1) Name of the Policyholder / insured (s)
2) Date of Birth/Age
3) Address of the policyholder/insured
4) Details of existing insurer
i. Name of insurance company
ii. Name of the product
iii. Sum Insured
iv. Cumulative Bonus
v. Add-ons/riders taken
vi. Policy number
5) Details of the proposed insurance
i. Name of the product proposed/intend to take
ii. Sum Insured Proposed
iii. Whether Cumulative Bonus to be converted
to an enhanced sum insured
6) Reason(s) for Portability
7) No. of family members to be included in the
policy to be ported
Enclosure: Photocopy of the existing & previous policy documents
Date:
Signature of the policyholder
1. Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy? (Please
indicate Yes / NO):
2. If yes, please give written consent to the declaration below:
I am aware that the waiting period for the following disease(s)/treatment(s) is more than the previous policy terms. I
hereby agree to observe the additional waiting period for the following disease(s)/treatment(s).
Name of disease/ treatment Waiting period in days/ years
1.
2.
3.
4.
Place : _____________________________________
Date : Signature of the policyholder
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 5 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
National Insurance Co. Ltd. Annexure C
Documents required
1. Completed proposal form
2. Cancelled cheque (supporting bank account details)
3. Stamp size photograph (1 nos) for each insured person
4. Pre policy check up reports (if applicable)
5. Copy of existing health insurance policies (if applicable)
6. Proof of identity (any one document listed below)
7. Proof of residence (any one document listed below)
8. Copy of IT Certificate/ IT Return (wherever applicable)
9. Pan Details (in case PAN not available, Form 60 or 61 as per Rule 114B of the Income-tax Rule, 1962 must be submitted)
Documentary proof
Features Documents
i. Passport
ii. PAN Card
iii. Voter’s Identity Card
iv. Driving License
v. Letter from a recognized Public Authority (as defined under Section 2 (h) of the Right to
Proof of identity Information Act, 2005) or Public Servant (as defined in Section 2(c) of the ‘The Prevention of
Corruption Act, 1988’) verifying the identity and residence of the customer
vi. Personal identification and certification of the employees of the insurer for identity of the
prospective policyholder.
vii. Letter issued by Unique Identification Authority of India containing details of name, address and
Aadhar number
viii. Job card issued by NREGA duly signed by an officer of the State Government
i. Telephone bill pertaining to any kind of telephone connection like, mobile, landline, wireless, etc.
provided it is not older than six months from the date of insurance contract
ii. Current Passbook with details of permanent/present residence address (updated upto the previous
month)
iii. Current statement of bank account with details of permanent/present residence address (as
downloaded)
Proof of Residence iv. Letter from any recognized public authority
v. Electricity bill
vi. Ration card
vii. Valid lease agreement along with rent receipt, which is not more than three months old as a
residence proof
viii. Employer’s certificate as a proof of residence (Certificates of employers who have in place
systematic procedures for recruitment along with maintenance of mandatory records of its
employees are generally reliable)
Proofs of both Identity and Written confirmation from the banks where the proposer is a customer, regarding identification and proof
Residence of residence.
National Insurance Co. Ltd.
National Mediclaim Policy
Regd. & Head Office: Premises No. 18-0374, Page 6 of 6
UIN: NICHLIP25036V082425
Plot no. CBD-81, New Town, Kolkata – 700156
