THE ORIENTAL INSURANCE COMPANY LIMITED
Regd. Office : 'ORIENTAL HOUSE' P.B. No.7037, A 25/27, Asaf Ali Road, New Delhi - 110 002.

Proposal Form for OMP Policy (E & S)
(To be submitted in original with two copies)
(Available to persons in the age group of 18 – 60 years)

1.0 PERSONAL DETAILS:
1.1 Name (Mr. / Mrs./ Miss/ Master) _____________________________________________________
(BLOCK LETTER)
1.2 Sex: Male / Female
1.3 Date of Birth: _______/_______/________ Age_________________________
DD MM YY
1.4 Height: ____________ ft _________in (_________ cms.) Weight: __________ lbs ________(kgs)
1.5 Passport No.: ___________________________________
1.6 Date of Issue: _________________________________
1.7 Type of Visa Held: F1 ____________ J1___________ H1_____________________Any other _____
(Student) (Research) (Temporary Employment)
1.8 State Type: ______________________________________
1.9 Is the Proposed Person a spouse or child of an Insured Person (participant), if so state Policy Number
___________________ of Insured Person and Passport No. ______________________ of Participant.
ELIGIBILITY:
This Insurance is specially designed for you if you are an Indian Citizen residing or will be
proceeding shortly temporarily outside India solely for the purpose of EITHER
1. furthering your education ; OR
2. engaging in research activities ; OR
3. temporary posting in a sedentary non-manual work, provided you are a holder of a appropriate
and valid visa for the same purpose issued by the authorities in India.
IMPORTANT NOTICES:
If a spouse or a child accompanying you is/are also to be covered, a separate proposal form should
be completed by each accompanying person.
You must complete and sign a Proposal Form to the best of your knowledge and belief and all
materials facts* must be disclosed. An adult may complete and sign on behalf of his child aged 18
years or less
* A material fact is one that is likely to influence the acceptance or assessment of the
Proposal. You should consult the Insurance Company if you are in any doubt as to what
constitutes a material fact.
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2.0 Your address in India: _______________________________________________________________
______________________________________________________Tel No. _____________________
2.1 Your Next to Kin (Mr. / Mrs./ Miss): ___________________________________________________
2.2 Relationship: _______________________________________________________________________
2.3 Address: __________________________________________________________________________
____________________________________________________ Tel No. ______________________
3.0 YOUR COUNTRY OF VISIT:
3.1 Country of Studying or Posting: __________________________________
3.2 Address in country of studying or posting: ________________________________________________
___________________________________________________ Tel No. ________________________
3.3 Name and Address of School / work place you are attending: _________________________________
___________________________________________________ Tel No. ________________________
4.0 Brief details of nature of future studies / research and activities /or employment /employment to be
undertaken: ________________________________________________________________________
_____________________________________________From _____/______ To ______/_________
MM YY MM YY
4.1 Name and address of Indian Sponsor: ___________________________________________________
__________________________________________________________________________________
________________________________________________ Relationship _______________________
5.0 Period of Insurance required: ___________________________________________________________
5.1 Commencement Date: ______/ ______/ ______
DD MM YY
5.2 Total period of months that you are intending to study/work in the country of study / posting: _____
months.
6.0 YOUR MEDICAL HISTORY:
PLEASE ANSWER THE FOLLOWING QUESTIONS IN YES OR NO (A DASH IS NOT SUFFICIENT)
6.1 Are you in good health and free from physical defect or infirmity? ____________________________________
6.2 Do you ordinarily enjoy good health? ___________________________________
6.3 Have you ever suffered from:
a. any nervous or mental condition, fainting episode, blackout fit or paralysis of any kind ?_____
_______________________________________________________
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b. high blood pressure, a heart condition, hemorrhoids, varicose veins, or other circulatory
disorder, rheumatic fever or diabetes?________________________________
c. a “slipped disc” or other spinal disorder, a hernia, or any rheumatic or arthritic condition ?
____________________________________________
d. any respiratory, urinary or allergic condition, or any disorder of the stomach or bowels ?
____________________________________________
e any other condition requiring specialist consultation or surgical or hospital treatment in the
future?____________________________________________
f any symptom or tendency that might necessitate such consultation or treatment in the future ?
_____________________________________________
6.4 Have you any intention of engaging in winter sports or any other sports or pastimes rendering you
liable to personal injury? ____________________________________
6.5 Are there any additional facts affecting the proposed insurance which should be disclosed to insurers?
_________________________________________________
6.6 Name and address of usual medical physician in India _______________________________________
___________________________________________________________________________________
___________________________________________________________ Tel No. ________________
7.0 Please attach a copy of your medical report, if any, which was required for Entry Visa or Application to
Study.
7.1 If your answer is YES to any of the questions 6.3 (c) to (f), __________________________________
Please give full details with dates _______________________________________________________
8.0 DECLARATION:
Please read IMPORTANT NOTICES above before your signing.
I hereby declare and warrant that the above statements are true and complete. I consent to the Insurance
Company and / or their appointed Claims Administrator seeking medical information from any Doctor
who has at any time attended concerning anything which affects my physical or mental heath, and I
authorise the giving of such informat ion. I agree that this Proposal shall form the basis of the contract
of Insurance.
I am willing to accept the Policy, subject to the terms, exceptions and conditions prescribed by the
Insurance Company therein.
Date: _____ / ______ / _______ Signature: ________________
DD MM YY
Place: ____________________
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9.0 STUDY:
If you are under 18 years of age and / or residing with your parent (s), one of your parents must confirm
the accuracy of the information provided in this proposal by signing below:
Date: _____ / ______ / _______ Signature of Parent (or Guardian): _________________
DD MM YY
Place: ___________________
10.0 EMPLOYMENT:
If you are being posted overseas by an Indian Employer, the competent official of your Company must
confirm the accuracy of the information provided in this proposal by signing below :
Date: ____ / _____ / _____ Employer’s competent official’s signature: ______________
DD MM YY N ame: ___________________________________________
Designation: ______________________________________
Place: ________________ Seal: ____________________________________________
I M P O R T A N T
IF YOU ARE NOT ABLE TO SIGN THIS DECLARATION AND WARRANTY AT THE TIME OF
PROPOSAL, OR HAVING SIGNED THE DECLARATION AND THEREAFTER
CIRCUMSTANCES CHANGE BEFORE THE FIRST DAY OF INSURANCE WHEREBY THE
DECLARATION IS RENDERED INVALID, YOU MUST INFORM THE INSURANCE COMPANY
FOR FURTHER ADVICES.
U N D E R T A K I N G
I, Mr. / Mrs. / Miss / Master ____________________________________________________________
do hereby agree and undertake to refund to The Oriental Insurance Company Ltd. providing the
insurance (hereinafter referred to as the Insurers) all medical related expenses, made by Insurer’s
Claims Administrators on my behalf which expenses are found to be not payable as per terms and
conditions of the Policy and which expenses are required to be reimbursed by the Insurers to the
Claims Administrators under the agreement made between the Insurers and their Claims
Administrators. Such payments would be refunded by me to the Insurers in Indian rupees immediately.
Signature of Proposer: ________________________
Date: ____/____/_____
DD MM YY
Place: ______________
MEDICAL EXAMINATION: (TO BE COMPLETED BY A DOCTOR WHO HOLDS A M.D. DEGREE)
N O T E: If the Proposer:-
a. is over 40 years of age and is travelling to USA / CANADA
b. Answer to the questions posed under the Medical History Section of this form indicates that
the proposal represents in the view of the Insurers a materially sub Standard Risk,
the Proposer should make arrangements for a Medical Examination by a Doctor taking with him this
proposal in order that the Doctor completes the section, which follows below.
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TO BE COMPLETED BY THE DOCTOR
1. a. History
b. Any past history of disease,
Operation, accidents, investigations etc.
c. General Examination.
d. Systemic Examination.
2. Electrocardiograpy:
a. Does the attached Electrocardiogram
in your professional opinion show any
abnormalities and if so, please describe :
b. Does the abnormality represent a current
illness or disease which may possibly be expected
to require medical treatment during proposer’s
forthcoming trip? :
c. Does the proposer now or did he/she in the past
require medication for this abnormality? :
d. Please describe any treatment taken by the proposer
in the past or being taken at present ? :
e. Do you consider that the proposer is fit to travel
anywhere abroad, due account being taken of the
stress of air travel adversely affecting his
medical condition? :
3. Does the Fasting Blood and Urine Sugar, Urine Strip Test
show any Sugar? :
Signature of Doctor : ________________________________________________
Name of Doctor : ________________________________________________
Qualifications : ________________________________________________
Address :_________________________________________________
_________________________ Tel No. _________________
SECTION – 41 OF INSURANCE ACT 1938
PROHIBITON OF REBATES
1. No persons shall allow or offer to allow either directly or indirectly as an inducement to any
person to take put or renew or continue an 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 labels of the insurers.
2. Any persons making default in complying with the provisions of this section shall be
punishable with fine which may extend to five hundred rupees.
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