star_commonproposal_form_new.pdf
DESCRIPTION
PropoalTRANSCRIPT
Proposal Form No:
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
PROPOSAL FORM
Business: Urban / Rural
Please fill up the form in block letters. Also submit photograph of each person proposed for insurance for issuance of identity cards.
Name of the Proposer
Policy Issuing Office
Occupation of the Proposer
Residence Address
Office Address
Mobile No.
Period of Insurance
Email ID
From To
IT PAN No.
Pin Code:
Pin Code:
Annual Income Rs.
The company will not be on risk until the proposal has been accepted and full payment of premium has been received.
Please affix recent photographs of persons proposed for insurance
Insu
red
Per
son
Det
ails
(P
leas
e fi
ll in
th
e re
spec
tive
co
lum
n f
or
each
of
the
per
son
pro
po
sed
to
be
cove
red
)
In
sure
d P
erso
n -
1
In
sure
d P
erso
n -
2
Insu
red
Per
son
- 3
I
nsu
red
Per
son
- 4
I
nsu
red
Per
son
- 5
Ack
no
wle
dg
men
t
Rec
eive
d th
e pr
opos
al f
or t
he o
pted
Sta
r In
sura
nce
Pol
icy
from
Mr./
Mrs
.Ms.
____
____
____
____
____
____
____
____
____
____
____
____
alo
ng w
ith p
aym
ent
of R
s. _
____
____
____
____
____
____
_/-
by C
ash/
vid
e C
hequ
e N
o. _
____
____
____
____
___
date
d __
____
____
____
___
draw
n on
___
____
____
____
____
____
____
____
____
____
_. T
he c
ash/
cheq
ue g
iven
by
you
is b
anke
d fo
r ope
ratio
nal c
onve
nien
ce a
nd b
anki
ng o
f the
cas
h/ch
eque
doe
s no
t mea
n ac
cept
ance
of r
isk
by u
s. T
he re
ceip
t of t
he c
ash/
cheq
ue
will
als
o be
ack
now
ledg
ed b
y ou
r offi
ce v
ide
adva
nce
prem
ium
rece
ipt i
n re
spec
t of
prop
oser
/s re
ferr
ed fo
r med
ical
exa
min
atio
n. If
the
prop
osal
is a
ccep
ted,
the
cove
r will
com
men
ce fr
om th
e da
te o
f the
adv
ance
pre
miu
m re
ceip
t sub
ject
to re
aliz
atio
n of
the
cheq
ue. I
f the
prop
osal
is n
ot a
ccep
ted,
the
amou
nt p
aid
will
be
refu
nded
by
our c
hequ
e.
Sig
nat
ure
of t
he
Insu
rer/
Au
tho
rise
d R
epre
sen
tati
veS
ign
atu
re o
f th
e P
rop
ose
r Ö
Pro
hib
itio
n o
f reb
ates
: (S
ectio
n 41
of t
he In
sura
nce
Act
) N
o pe
rson
sha
ll al
low
or o
ffer t
o al
low
eith
er d
irect
ly o
r ind
irect
ly a
s in
duce
men
t to
take
out
rene
w o
r con
tinue
an
insu
ranc
e in
resp
ect o
f any
kin
d of
risk
rela
ting
to li
ves
or p
rope
rty
in In
dia
any
reba
te o
f the
who
le o
r par
t of t
heco
mm
issi
on p
ayab
le o
n th
e pr
emiu
m s
how
n on
the
polic
y no
r sha
ll an
y pe
rson
taki
ng o
ut re
new
ing
or c
ontin
uing
a p
olic
y ac
cept
any
reba
te e
xcep
t suc
h re
bate
as
may
be
allo
wed
in a
ccor
danc
e w
ith th
e pu
blis
hed
pros
pect
us o
r tab
les
of th
e In
sure
r. A
ny p
erso
n m
akin
g de
faul
t in
com
plyi
ng
with
the
prov
isio
n of
this
sec
tion
shal
l be
puni
shab
le w
ith fi
ne, w
hich
may
ext
end
to F
ive
Hun
dred
Rup
ees.
Dec
lara
tio
n:
I he
reby
dec
lare
and
war
rant
that
the
abov
e st
atem
ents
are
true
and
com
plet
e. I
cons
ent a
nd a
utho
rize
the
insu
rer t
o se
ek a
ny in
form
atio
n re
gard
ing
the
med
ical
his
tory
of t
he p
erso
ns p
ropo
sed
from
any
med
ical
est
ablis
hmen
t/med
ical
pra
ctiti
oner
/em
ploy
er/a
ny p
erso
n. I
agre
e th
at th
is p
ropo
sal s
hall
form
the
basi
s of
the
cont
ract
sho
uld
insu
ranc
e be
effe
cted
. If i
t is
foun
d th
at th
e st
atem
ents
, par
ticul
ars,
dec
lara
tions
, con
nect
ed d
ocum
ents
or a
ny o
ther
info
rmat
ion
prov
ided
in th
e pr
opos
al fo
rm a
re in
corr
ect o
r unt
rue
or th
ere
is fa
ilure
to d
iscl
ose
any
mat
eria
l pa
rtic
ular
s as
cal
led
for a
bove
, the
insu
ranc
e co
mpa
ny in
cur n
o lia
bilit
y un
der t
his
polic
y. I
have
read
the
term
s of
this
insu
ranc
e an
d I a
m w
illin
g to
acc
ept t
he c
over
age
prov
ided
by
the
Com
pany
.T
he te
rmin
olog
y in
the
prop
osal
form
with
the
term
s an
d co
nditi
ons
of th
e po
licy
and
sche
dule
are
exp
lain
ed to
me
in th
e ve
rnac
ular
lang
uage
(mot
her t
ongu
e).
In c
ase
of s
ing
le A
du
lt b
ein
g c
ove
red
alo
ng
wit
h C
hild
ren
: I h
ereb
y co
nfirm
and
war
rant
that
I am
a s
ingl
e pa
rent
of t
he C
hild
/Chi
ldre
n pr
opos
ed.
Pla
ce:
Dat
e:S
ign
atu
re o
f th
e P
rop
ose
r A
ckn
ow
led
gm
ent
Rec
eive
d th
e pr
opos
al fo
r th
e op
ted
Sta
r In
sura
nce
Pol
icy
from
Mr./
Mrs
.Ms.
____
____
____
____
____
____
____
____
____
____
____
____
___
alon
g w
ith p
aym
ent o
f Rs.
____
____
____
___/
- by
Cas
h/ v
ide
Che
que
No.
___
____
____
____
____
____
____
____
date
d __
____
____
____
_ dr
awn
on _
____
____
____
____
____
____
____
____
____
___.
The
cas
h/ch
eque
giv
en b
y yo
u is
ban
ked
for o
pera
tiona
l con
veni
ence
and
ban
king
of t
he c
ash/
cheq
ue d
oes
not m
ean
acce
ptan
ce o
f ris
k by
us.
The
rece
ipt o
f the
cas
h/ch
eque
will
als
o be
ack
now
ledg
ed b
y ou
r offi
ce v
ide
adva
nce
prem
ium
rece
ipt i
n re
spec
t of
prop
oser
/s re
ferr
ed fo
r med
ical
exa
min
atio
n. If
the
prop
osal
is a
ccep
ted,
the
cove
r will
com
men
ce fr
om th
e da
te o
f the
adv
ance
pre
miu
m re
ceip
t sub
ject
to re
aliz
atio
n of
the
cheq
ue. I
f the
pro
posa
l is
not a
ccep
ted,
the
amou
nt p
aid
will
be
refu
nded
by
our c
hequ
e.
Sig
nat
ure
of t
he
Insu
rer/
Au
tho
rise
d R
epre
sen
tati
ve
S
ign
atu
re o
f th
e P
rop
ose
r
Ö
Ö
SP
C-2
4.0
8.1
2-5
0K
-PO
:03
2
420 x 280mm
Sta
r H
ea
lth
And
Alli
ed
In
su
ran
ce
Co
mpa
ny L
imite
d
Hav
e an
y o
f th
e p
erso
ns
pro
po
sed
fo
r in
sura
nce
:
1. U
nder
gone
any
med
ical
test
?
2. P
resc
ribed
any
med
icat
ion
i) N
ame
of th
e ill
ness
for
whi
ch m
edic
ines
h
ave
been
pre
scrib
ed.
iii)P
erio
d fr
om w
hich
thes
e dr
ugs
are
take
n.
ii) D
etai
ls o
f Dru
gs a
nd M
edic
ines
pre
scrib
ed.
3. B
een
advi
sed
for
any
surg
ery?
If ye
s, p
leas
e gi
ve d
etai
ls
4. R
ecei
ved
/ Rec
eivi
ng p
aym
ent f
or a
ny
d
isab
ility
/ in
jury
/ ill
ness
/ di
seas
e
5. A
ddic
ted
to:
i)
Che
win
g To
bacc
o -
If ye
s, s
ince
whe
n
ii) S
mok
ing
- If
yes,
sin
ce w
hen
iii)
Con
sum
ing
Alc
ohol
- If
yes
, sin
ce w
hen
iv)
Any
oth
er A
ddic
tion
- If
yes,
sin
ce w
hen
Are
yo
u p
osi
tive
fo
r H
IV. I
f yes
, ple
ase
men
tion
your
CD
4co
unt (
Pl.
atta
ch p
roof
)
6. D
oes
your
Occ
upat
ion
requ
ire y
ou to
eng
age
in
man
ual l
abou
r ?
7. D
o yo
u en
gage
in o
r pro
pose
to e
ngag
e in
any
act
ivity
or
spor
t whi
ch is
haz
ardo
us o
r adv
entu
rous
in n
atur
e su
ch a
s R
acin
g,M
ount
aine
erin
g, W
inte
r spo
rt, e
tc.,i
fso
plea
se s
peci
fy
Please the Policy opted ( ü)
Super surplus Criticare Plus
Mediclassic
Family HealthOptima
Health Gain
Star Unique
Mediclassic Accident CareFamily HealthOptima Accident Care
Star Family Delite
Please Sum Insured Opted( ü)
3,50,000/-
1,50,000/-
2,00,000/-
2,50,000/-
3,00,000/-
4,00,000/-
5,00,000/-
10,00,000/-
15,00,000/-
Sum Insured (Rs.)
Hea
lth
Acc
iden
t
Sum Insured (Rs.)
Hea
lth
Acc
iden
t
Please Family Size( ü)
1A
1A + 1C 2A + 1C
1A + 2C 2A + 2C
1A + 3C 2A + 3C
Family Size Family Size
Op
tio
n
Op
tio
n
2A
A = Adult C = Child
Annual Premium Rs.Payment Details
Cash Cheque No. Date Drawn on Branch
Please attach any of the following proof of Date of Birth
q Birth Certificate q Voter ID q q q q PAN Card Driving License Aadhar ID Card (UID) Any other Govt. Recognised proof
Family Physician’s NameFamily Physician’s Name Phone No. Regn. No.
Ref. No.
Policy No.
Please affixphotograph of
Insured Person - 1
Please affixphotograph of
Insured Person - 2
Please affixphotograph of
Insured Person - 3
Please affixphotograph of
Insured Person - 4
Please affixphotograph of
Insured Person - 5
Name Name Name Name Name
Insured Person - 1 Insured Person -2 Insured Person -3 Insured Person - 4 Insured Person - 5
Add-on covers : Hospital cash
Patient care
3. H
ave
you
eve
r su
ffer
ed o
r su
ffer
ing
fr
om
an
y o
f th
e fo
llow
ing
:-
a) D
iabe
tes
Mel
litus
- If
yes
, sin
ce w
hen
b) H
igh
BP,
Cho
lest
erol
- If
yes
, sin
ce w
hen
c) H
eart
Dis
ease
- I
f yes
, sin
ce w
hen
d) S
trok
e, e
pile
psy,
fain
ting
atta
ck, c
hron
ic
head
ache
- If
yes
, sin
ce w
hen
e) T
uber
culo
sis,
ast
hma,
oth
er r
espi
rato
ry
infe
ctio
ns -
If y
es, s
ince
whe
n
f) A
ny d
isea
se o
f bon
es/jo
ints
, slip
ped
disc
,sp
inal
dis
orde
r, in
jury
to li
gam
ents
-
If ye
s, s
ince
whe
n
g) C
ance
r, P
re c
ance
rous
Les
ion
- If
yes,
sin
ce w
hen
h) A
ny g
ynae
colo
gica
l dis
orde
r su
ch a
s
DU
B, F
ibro
id U
teru
s, O
varia
n cy
st -
If
yes,
sin
ce w
hen
i) D
isea
ses
of s
tom
ach,
inte
stin
e, li
ver,
gall
blad
der/
panc
reas
, Kid
ney,
ur
inar
y bl
adde
r, U
rinar
y Tr
act D
isea
ses
- If
yes,
sin
ce w
hen
j) D
isea
se o
f pro
stra
te/ f
istu
la/p
iles/
Gen
ital d
isea
ses
- If
yes,
sin
ce w
hen
k) C
atar
act,
dise
ases
of e
ye a
nd
EN
T di
seas
es -
If y
es, s
ince
whe
n
l) A
ny o
ther
pro
blem
(P
leas
e sp
ecify
)
Insu
red
Per
son
Det
ails
(P
leas
e fi
ll in
th
e re
spec
tive
co
lum
n f
or
each
of
the
per
son
pro
po
sed
to
be
cove
red
)
Insu
red
Per
son
- 1
In
sure
d P
erso
n -
2
Insu
red
Per
son
- 3
I
nsu
red
Per
son
- 4
I
nsu
red
Per
son
- 5
Sig
nat
ure
of
the
Pro
po
ser Ö
Sig
nat
ure
of
the
Pro
po
ser Ö
Det
ails
of
oth
er/P
revi
ou
s In
sura
nce
, if
any
1. N
ame
of th
e In
sura
nce
Com
pany
2. P
erio
d of
Insu
ranc
e
3. S
um In
sure
d (R
s.)
4. P
olic
y N
o:
Det
ails
of
Cla
ims:
1. A
ilmen
t for
whi
ch c
laim
was
mad
e.
2. C
laim
am
ount
pai
d / r
ejec
ted
3. Y
ear
of c
laim
Hea
lth
His
tory
:P
leas
e p
rovi
de
answ
er in
det
ail.
A m
ere
das
h is
no
t su
ffic
ien
t.
1. A
re y
ou in
goo
d he
alth
and
free
from
ph
ysic
al a
nd m
enta
l dis
ease
or
infir
mity
. If
not,
give
det
ails
.
2. H
ave
you
cons
ulte
d/ta
ken
trea
tmen
t/bee
n ad
mitt
ed fo
r an
y ill
ness
/dis
ease
s/in
jury
. If
yes,
det
ails
.
Insu
red
Per
son
Det
ails
(P
leas
e fi
ll in
th
e re
spec
tive
co
lum
n f
or
each
of
the
per
son
pro
po
sed
to
be
cove
red
)
Nam
e o
f th
e p
erso
n p
rop
ose
d
for
insu
ran
ce
Sex
Dat
e o
f B
irth
Hei
gh
t (c
ms)
Wei
gh
t (k
gs)
Rel
atio
nsh
ip w
ith
pro
po
ser
Occ
up
atio
n
An
nu
al In
com
e (R
s.)
No
min
ee’s
nam
e
No
min
ee’s
ag
e
Rel
atio
nsh
ip o
f th
e n
om
inee
to
th
ein
sure
d P
erso
n
Insu
red
Per
son
- 1
In
sure
d P
erso
n -
2
In
sure
d P
erso
n -
3
Insu
red
Per
son
- 4
Insu
red
Per
son
- 5