UNITED INDIA INSURANCE CO. LTD
At United India, It’s always U before
Email :insurancediv [at] syndicatebank [dot] co [dot] in
SYNDAROGYA PROPOSAL FORM
Group Mediclaim Insurance Cum Personal Accident for Syndicate Bank Account Holders
1. NAME & ADDRESS OF THE ACCOUNT HOLDER (in CAPITAL
letters)
2. SUM INSURED PER FAMILY (Please tick (
) :
Rs.0.50 lacs Rs.1.00 lac Rs.1.50 lacs Rs.2.00 lacs Rs.2.50 lacs
Rs.3.00 lacs Rs.3.50 lac Rs.4.00 lacs Rs.4.50 lacs Rs.5.00 lacs
(To be filled by the Bank)
3 a. Branch Name/City
b. BIC Code
c. Proposal from (Please tick (
)
Rural/Semi Urban/Urban
4. Account No.
SB/CA/FD/others (Pl. specify)
5. DETAILS OF PERSONS TO BE COVERED - (Please tick (
) :Under Plan A ( ) Under Plan B ( )
SL
NO
NAME OF THE
INSURED PERSON (in
CAPITAL letters)
AGE SEX
RELATIONSHIP EXISTING DISEASE /
ILLNESS / INJURY
I
II
III
IV
V
*Additional sheets may be used wherever required.
6. STAMP SIZE PHOTOGRAPH OF THE INSURED PERSONS :
ACCOUNT
HOLDER
SPOUSE CHILD 1 CHILD 2 PARENT 1 PARENT 2
7. NAME OF THE T.P.A : M/S. TTK HEALTH SERVICES PVT. LTD., [ ]
M/S. MEDIASSIST HEALTH SERVICES PVT.LTD. [ ] M/S. E-MEDITEK SOLUTIONS LTD. [ ].The TPA will be automatically selected by United India Insurance Co.Ltd , and hence need not be ticked
8. I hereby declare and agree that the above statements are true and complete. Myself and my family members are maintaining good health except the existing diseases/illness/injury as per Serial No. 5 above.I have read the salient features of the policy and willing to accept the cover subject to the terms, conditions and exceptions prescribed by the Insurance Company. Enclose copy of existing medical insurance of account holder or other family members.
I / we agree that Syndicate Bank is no way responsible for claims under SyndArogya and same have to be pursued with the particular T.P.A. / Insurance Company.
PLACE …………… (X)
DATE …………….. SIGNATURE OF THE PROPOSER
SEAL OF THE BRANCH SIGNATURE OF BRANCH MANAGER
PREMIUM CHART - PLAN A (Family size: 1+3) inclusive of service tax @ 12.36%
PREMIUM CHART - PLAN A (Family size: 1+3) inclusive of service tax @ 12.36%
Sum 0.50 1.00 1.50 2.00 2.5 3.00 3.5 4 4.5 5
insured lacs lacs lacs lacs lacs lacs lacs lacs lacs lacs
Premium 956 1,848 2,709 3,488 4,181 4,875 5,484 6,094 6,706 7,316
PREMIUM CHART - PLAN B (Family size: 1+5) inclusive of service tax @ 12.36%
Sum 0.50 1.00 1.50 2.00 2.5 3.00 3.5 4.00 4.5 5.00
insured lacs lacs lacs lacs lacs lacs lacs lacs 1acs lacs
Premium 1,597 3,085 4,519 5,815 6,967 8,120 9,131 10,143 11,156 12,167
EXCLUSIONS:
1. All diseases / injuries which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of the initial Medical Policy taken from any Indian Insurance companies shall be taken provided the renewals have been continuous and without any break.However, this exclusion will be deleted after three consecutive continuous claims free policy years, provided, there was no hospitalisation forth pre existing ailment during these years of Insurance.
2. Any disease other than those stated in clause 3 under exclusions, contracted by the insured person during the first 30 days from the commencement date of the policy. The condition shall not however apply in case of the insured person having been covered under this scheme or group Insurance Scheme with any of the Indian Insurance companies for a continuous period of preceding 12 months without any break.
3. During the first year of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, piles, Sinusitis and related disorders are not payable. if these disease (other than Congenital Internal Disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of the policy, the same will be treated as pre-existing and however subject to Exclusion No.l.
4. Injury / disease directly or indirectly caused by or arising from or attributable to invasion, Act of Foreign enemy, war like operations (whether war be declared or not)
5. Circumcision unless necessary for treatment of disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
6. Cost of spectacles and contact lenses, hearing aids.
7. Dental treatment or surgery of any kind including hospitalisation either due to Accident / Disease.
8. Convalescence, general debility, rundown condition or rest cure. Congenital external disease or defects or anomalies, Sterility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol.
9. All expenses arising out of any condition directly or indirectly caused to or associated with Human TCell Lymphotropic Virus Type III (HTLB-III) or Lympadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
10. Charges incurred at Hospital or Nursing Home primarily for Diagnosis, X-ray or Laboratory examinations other diagnostic studies not consistent with or incidental to the diagnosis and treatment of Positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
11. Expenses on vitamins and tonics unless forming part of treatment for injury / disease as certified by the attending physician.
12. Injury or Disease directly caused by or contributed to by nuclear weapon / materials.
13. Treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and child birth (including caesarean section).
14. Naturopathy treatment.
Three sets of application to be obtained. The 1st and 2nd copy to be sent to UIICO Ltd. & the 3rd copy to
be retained at the branch. Stamp sized photo to be affixed on the first copy only.
Encl: DD No……………………Date……………..favoring UIICO Ltd. for Rs…………………………