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    Senior Citizens Red Carpet Health Insurance Policy

    Uploaded by

    Bhakti
    1) This document appears to be an insurance proposal form for a Senior Citizens Red Carpet Health Insurance Policy from Star Health and Allied Insurance Company. 2) It requests information such as the proposer's name, address, occupation, income, family physician's details, and payment method. 3) The form also seeks details of up to two insured persons, including their name, date of birth, photograph, and sum insured opted. Nominee details are also required if the nominee is a minor.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Senior Citizens Red Carpet Health Insurance Policy

    Uploaded by

    Bhakti
    108 views3 pages
    1) This document appears to be an insurance proposal form for a Senior Citizens Red Carpet Health Insurance Policy from Star Health and Allied Insurance Company. 2) It requests information such as the proposer's name, address, occupation, income, family physician's details, and payment method. 3) The form also seeks details of up to two insured persons, including their name, date of birth, photograph, and sum insured opted. Nominee details are also required if the nominee is a minor.

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    Senior-Citizens-Red-Carpet-Health-Insurance-Policy (1).docx

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    1) This document appears to be an insurance proposal form for a Senior Citizens Red Carpet Health Insurance Policy from Star Health and Allied Insurance Company. 2) It requests information such as the proposer's name, address, occupation, income, family physician's details, and payment method. 3) The form also seeks details of up to two insured persons, including their name, date of birth, photograph, and sum insured opted. Nominee details are also required if the nominee is a minor.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    108 views3 pages

    Senior Citizens Red Carpet Health Insurance Policy

    Uploaded by

    Bhakti
    1) This document appears to be an insurance proposal form for a Senior Citizens Red Carpet Health Insurance Policy from Star Health and Allied Insurance Company. 2) It requests information such as the proposer's name, address, occupation, income, family physician's details, and payment method. 3) The form also seeks details of up to two insured persons, including their name, date of birth, photograph, and sum insured opted. Nominee details are also required if the nominee is a minor.

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    You are on page 1of 3

    Proposal Form No.

    STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED


    Pe rs o n a l & C a r i n g
    Health Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
    Insurance
    The Health Insurance Specialist Chennai - 600 034.  Phone : 044 - 28288800  Email : [email protected]
    Website : www.starhealth.in  CIN : U66010TN2005PLC056649  IRDAI Regn. No. : 129

    SENIOR CITIZENS RED CARPET HEALTH INSURANCE POLICY Ref. No.


    Unique Identification No.: IRDA/NL-HLT/SHAI/P-H/V.II/172/14-15
    Proposal Form - Unique Reference No.: SHAI/PR0011 Policy No.

    The company will not be on risk until the proposal has been accepted and full payment of premium has been received.
    Please fill up the form in block letters. Also submit photographs of each of the person proposed for insurance for issuance of identity cards
    Policy Issuing Office : SM
    SM CODE
    NAME
    AGENT AGENT
    CODE NAME

    BUSINESS TYPE Social Sector Classification* :  Yes  No Rural Sector Classification :

    If Yes :  a. Unorganised Sector  c. Other Categories of Persons  Urban  Rural


    This classification is based upon
     b. Economically Vulnerable or Backward Classes  d. Informal Sector the address of the proposer
    * “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural
    and urban areas.
    a. “Unorganised sector” includes self-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction
    workers, fishermen, hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather and tannery workers, papad makers, powerloom
    workers, physically handicapped self-employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers,
    sugarcane cutters, tendu leaf collectors, toddy tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and
    coolies or such other categories of persons;.
    b. “Economically Vulnerable or Backward Classes” means persons who live below the poverty line;
    c. “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of Rights and
    Full Participation) Act, 1995 and who may not be gainfully employed; and also includes guardians who need insurance to protect spastic persons or
    persons with disability;
    d. “Informal Sector” includes small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of
    generating employment and income, with heterogeneous activities like retail trade, transport, repair and maintenance, construction, personal and
    domestic services and manufacturing, with the work mostly labour intensive, having often unwritten and informal employer-employee relationship;

    Name of the Proposer


    Date of Birth :
    Mr / Mrs / Ms.
    Occupation of the
    Annual Income Rs.:
    Proposer
    Residence Address

    Health Pin Code :


    Office Address
    Pe rs o n a l & C a r i n g Insurance
    The Health Insurance SpecialistPin Code :
    Email ID : Mobile Number
    Period of
    Aadhar (UID) Number To
    Insurance

    GST Number PAN Number

    I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository Yes No
    If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number
    If no, choose any one Insurance Repository: KARVY CAMSRep - CAMS Insurance Repository & Services

    CIRL - Central Insurance Repository Limited NDML - NSDL Data Management Services limited

    Senior Citizens Red Carpet Health Insurance Policy 1 of 6


    Star Health and Allied Insurance Co. Ltd. Proposal Form

    NOMINATIO
    Nominee’s Name
    Relationship to Age :
    Date of Birth
    the Proposer
    N

    Name of the Appointee Relationship to Age :


    (if nominee is a minor) the Nominee
    ( Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee )

    Please affix Please affix


    photograph of photograph of
    Insured Person - 1 Insured Person - 2

    Name : Name :

    Sum Insured Opted (Please Tick) :

    Rs. 1,00,000  Rs. 2,00,000  Rs. 3,00,000  Rs. 4,00,000  Rs. 5,00,000 
    Rs. 7,50,000  Rs. 10,00,000 

    Family Physician's Name

    Phone Regn No

    Payments Details
    Annual Premium Rs.  Cash /  Cheque
    Cheque No. : Date : Drawn on : Branch :

    Account Number :

    Type of Account :  Savings  Current  Others please specify


    Bank Details of the proposer Name of the Bank :

    Name of the Branch :

    IFSC Code :
    Please attach a photo copy of cancelled cheque leaf of the above Bank Account.

    Please attach any of the following proof of Date of Birth


     Birth Certificate Voter ID PAN Card  Driving License Aadhar Card Any other Govt. Recognised Proof

    Senior Citizens Red Carpet Health Insurance Policy 2 of 6


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