Universal Health Insurance Policy
PROPOSAL FORM

AGENCY CODE ANNUAL PREMIUM POLICY NO.
DEV. OFFICER CODE
IMPORTANT
a) The Company will not be on risk until the proposal and Insured Person details have
been accepted by the Company and communication of the acceptance has
been given to the proposer in writing on full payment of premium.
b) If other family members residing with proposer i.e., spouse, eligible dependent
children and dependent parents required to be covered, separate Insured
Person details forms should be completed for each of such family members.
c) In case any family is identified as BPL family, a certificate as proof thereof issued
by an official not below the rank of B.D.O./ Tehsildar of Revenue Dept. of the
concerned State Government has to be attached.
1. Name of the Proposer :
2. Address :
3. DETAILS OF THE PERSONS TO BE INSURED :
Name of Insured
Person
Age Sex Indicate
Whether
earning
head of
family
Relatio
nship
with
the
Insured
Details of preexisting
diseases/
illness
Name of
nominee
(Only
applicable
to Head of
family)
Whether
belonging
to below
poverty
line (BPL)
Group
1.
2.
3.
4.
5.
6.
7.
Note : Please attach additional sheets for covering each family as per the above format.
(Minimum number for coverage 100 families)
4. Period of Insurance : From____________ To_____________
I/We, hereby declare that the details/information furnished above are true to the best of
my knowledge and belief.
Place :
Date : Signature of the proposer
PROHIBITION OF REBATES
(1) No person shall allow or offer to allow either directly or indirectly as an
inducement to any person to take our 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 a
part of commission payable or any rebates of the premium-shown on the policy
nor shall any person taking out or renewing continuing a policy except any
rebate as may be allowed in accordance with the published prospectus or
tables of the insurer.
(2) Any person making default in complying with the provisions of this section shall be
punishable with fine which may extend to five hundred rupees.