Activ Assure Diamond Proposal Form

Application No.:

1. Please select the appropriate options and-fill the form in BLOCK LETTERS.
2. Alldetails marked with (") are mandatory.
3. Please mention each information accurately as incorrect information may lead to policy cancellation/ claim rejection.
4. The Proposer must authenticate each cancellation/ alteration in this form .

Customer 10: Branch Stamp: (To be filled by Branch Official)

I. grcoposerDetails:.' : . ,"",' '. ' .

. Title": Female P'oB":

Correspondenc.e
Address*:

City* . Town (0istri ct)

State* PIN Code*

Contact Number*: STD Code Landline Number Mobile Number* .

Emergency Contact Number Name / RelationshiP :.::.=======

Emailld*: (All proposal/policy related communtcattonswill be sent on this e-mail Id)

ldentification Type" . PAN Card Passport Driving License

Please mention 10 Number ~ , ~ _ _ ..,.~_ _~ _ ••..._.

(PAN No is mandatory in case premium is > Rs 1,00,000 (irrespective of the mode

GST Registrat_ion Status *. Compounding Dealer

(mandatory for Registered dealer & Compounding dealer)

'UPI Handle

MaritalStatus

Cover*: Individual Family Floater

10% discount

Sum Insured (~)*:

Do you have Previous / Current policy far life, health, hospital daily cash or critical illness insurance?" Yes No
If Yes, Please fill the following details with respect to insurance policies(s) currently. held with Us or any other insurance company,

S No Prevlous/Durrent Insurance Details: * Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Ins.ured 6

1 Insurer Name
.__-_._
2 Claim in previou:r policy(Yes/No)#
.t----:-.

L3 Do you want to consider YOW health insurance

policy for Portability## (Yes / No)
"

. 'Please mention details of claim in 'INFORMATION ON HEALTH AND LIFESTYLE' section

"In case you want portability of previous policy, kindly fill portability form separately
 V. Insured Detalls ":
.- ._
, Insured ,
\
.'
1 2 3 4 5,. S
-
"
Name*

.'
Relationship with Proposer*
Date of Birth * (DD/MMIYYYY)
(Co-payment applicable for Age at entry ,
61·yrs & above)

Nationality*

City of Residence*'

Height* (ems)
l>
OJ
I Weight* (kgs) .
<;
:Eo Sum Insured* (to befitledseparately
o in caseof multi Individualpolicy) \
,_.
"-
-:" Optional Benefits Optionalcover underfamily floater policy if chosenwill be applicableto all membersin the policy except Cancerhospitalization booster
,_. (Please Tick) which is availablefor self + spouserelation.only,Please tick lnsuredL for family floater.
ce
~
-n Reductionin PreExisting
OJ
Diseasewaiting period to ,
d
,_. 24 months
o
Unlimited Reloadof Sum
Insured .
.
Super No Claim Bonus

Accidental Hospitalization
Boost-er(Not available above
Rs.l Cr Sum Insured)

CancerHospitalization
Booster
- Not available above Rs.l Cr
Sum Insured.
- Available abcveege of
18 yrs for Individual po!icy
- 'Available for self + spouse for
Family Floater

Any Room Upgrade

(Available with Sum Insured
Rs.S Lac and above) , ,

(.) Mandatory.

Discount applicable for Multi-individual policy·coverin~ 2 or more persons under same Policy.

Mode of Premium Payment

Cash Cheque Demand Draft Pay Order Credit Card Debit Card

Online IMPS/ NEFT/ RTGS

Instrument Number Instrument Date Instrument Amount (~) Nameof t<eI8t1UnS'"jJof Payerwith BankDetails
I PremiumPayer Proposer

.1

Mandatory details requiredto processall paym~nt due in relation to your policy including refunds (if. any) and / or claims directly to your bankaccount:

. Name.as in BankAccount: ---------- __ -~-----'-_-------~--------------

BankName: ~ Account Number: ------'----,----
Bank-Branch: _ IFSCCode:_. ,---:- __ - BankCity: _
Account Type(Current/Saving): _c_ _

Date:~ _ Place: ~_ Signature: ~------.---------

02
 Please answer the following questions in "Yes" OR "No" with respect to all persons proposed to be insured. Note _ Please answer all below mentioned questions for each
Insured. Please atta~h discharge card / summary; all consultation papers, investigation reports, histopathology repots, disability certificate from civil.surgeon if any.

Have. you ever been diagnosed with,/ advised / taken treatment or observation is suggested or
Insured 1 Insured 2 Insured 3 Insured 4
undergone any investigation or consulted a doctor or undergone or advised surgery for anyone' Insured 5 Insured 6
or more from the following?

If YES then please mention Details in 'the additional infonnation section below.

,*Ariy form of Heart Disease, Peripheral Vascular Disease, procedures like Angioplasty/PTCAIBy
Surgery, valve '.."f',a~e"rent etc

'Diabete~, High blood pressure, High Cholesterol, Anaemia / Blood disorder (whether treated or '--~~~Y ~.-.~ '--'.~
not).

'Tuberculosis.(TB), any .._ •• -i-:

/LlJr:lg disease ~·'~~~'.·_'_"A._~.~_
--.-".--,,-~--
'Disease of Eye, Ear,Nose,Throat, : ...................
t -
. "Cancer, Tumour, ulcer .. '"

....• _.
. ...
._ ..
'Disease of Kidney, Digestive tract, Liver.f(3all Bladder, Pancreas, Breast, Reproductive /Urinary
system, or any past complications of pregnancy/ child birth including high blood pressure or
diabetes etc
r-..r-r-r-r---------.-- _______ ._. _ ___:_,,
__ ._. ___
,,__
,,_~. ____

'Disease of the Brain/Spine/Nervous System, Epilepsy, Paralysis, Polio, Joints/Arthritis,

- --- ~---~-
Congenital! Birth defect, Genetic DiseaSe/Physical deformity/disability, HIV/AIDS, other
Sexually Transmitted Disease or Accidental injury or any other medical (other than common cold
& viral fever). or surgical condition or Investigation parameter has been detected to be out of
range/' not normal?

Was any proposal for life, health, hosptts! daily cash or critical illness insurance declined,
deferred, withdrawn or accepted with modified terms, if yes please provide details in. additional
information ,

Do you consume any of the following substances?(if yes, please mention the .quantity) .
..

'Alcohol [30ml ( number of pegs) of hard liquor/ pints of beer/ glass of winesJlWeek.

Smoking (Number of Cigarette/bidi sticks)/Week

Pan Masala/Gutkha (Number of small Pouches)/I!IIeek

Any Other substance (Name & Quantity)lWeek

Additional Infonnation: Please attach extra sheets if required

Meml;>erName
Details (Disease name, disability %, Date of Diagnosis,Last Consultation Date, Name of Surgery (if any), Details 'of Treatment
given(hospitalization/OPD)

I hereby declare, on my behalf and on

behalf of all persons proposed to be insured, that the above statements, answers and/' or particulars' given by me are true and
complete in all respects to the best of my. knowledge and that l.arn authorized to propose on behalf ofthese other persons.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the
policy will come into force only after full payment of the premium chargeable.

, I further declare that l will notify in writing enychangs occurring in the occupation or general health of the life to be insured/proposer after the proposal has been
submitted but before communication of the risk acceptance by the company'. ..

I declare that r consentto the companyseeking medical information from any doctor or hospital who/which at anytime has attended on the person to be
insured/proposer or from any past or present. employer concerning anything which affects the physical.or mental health of the person to be insured/proposer and seeking
information from any Insurer to whom an application for insurance on the person to be insured/proposer has been made for the purpose of underwriting the proposal
and/or claim settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured! proposer for tQe sole purpose of underwriting the ,
proposal and/or. claims settlement and with any Governmental and/or Regulatory authority. _

. Date:_~_~_---,_ Placer --,--_-:- _

Signature: -'----'-,__ -:- __

03
 I have explained the contents of this proposal form and all other documents incidental to health insurance from Insurer to the Proposer and-understood by hlrn/her, The
replies have been recorded as per the informatibn provided by and confirmed by the Proposer' .
Date: _
Declarant Signature: _
Declarant Name: -'- _

Proposer Name: ~.__--- Proposer Signature: --------

Proposer Sign date: Place:

Business Source Channel (Please tick the channel applicable and fill details in BLOCK letters)

Corporate Agency Direct Sales [~J Broker Other Channels

intermediary Details

tntsrmedlary Name
-"'-_"'-'-'-' -- ..
lntermediary Code

I, . . in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorised employee of

the Broker/Relationship Officer, do hereby \:teclare that I have explained all the contents of this p'roposal Form, including the nature of the questions contained in this propbsal
Form to the Proposer and that any details sought herein will form the basis of the Contract of Insurance between the Company and the Proposer,. I have further explained
that if any untrue st<!tement(s)/ information/response(s) is/are contained ifl this Proposal Form/including addendumis), affidavits, statements, submissions, furnished/to be
furnished, or if there has been a non-disclosure of any material fact, the policy issued in his/her favor pursuant to this Proposal may be treated as null and void by the
Company and all premiums paid under the policy may be forfeited to the company. I confirm that the proposal form is filled accurately by the customer to the best of my

knowledge. .

Signature of Agent
Date: _ (Insurance Advisor Sign.ed date cannot be prior to Customer's Signed date)

iNo

If Yes, please quote EIA Account Number: ------'---------------~

Please mentionname of Insurance Reposito!Y: -----'---'--~----------
, Yes No (if Yes, please fill up Insurance Repository Application Form)
If No, do you' want Us to create an EIA account for you:
Email id (Registered with Insurance' Repository) :.----'------------
Your address details as mentioned in the EIA account shall override the address provided in this application for Insur.ance.

Section 41 of Insurance Act 1938 (Prohibition of rebates):

1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take outor 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 cornmisslon payable or any rebate of 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 accorda'nce with the prospectus or tables of the insurers.
2) Any person making delault in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

Aditya Birla Health Insurance Co. Limited. IRDAI Reg.153. em No. U66000MH2015PLC263677.
Product Name: Activ Assure, Product UIN: ADIHLIP18077V01l718
Address> 10thFloor, R-Tech Park, Nirlon Compound, Next to HUB Mall, Off Western Express Highway, Goregaon East,
( outact u-.
Mumbai _ 400063. Email: [email protected]:adityabirlahealthinsurance.com <,
Fax: +912262257700. For more details on risk factors, terms and conditions please read terms and conditions carefully
I ~()II ::"11 '111111 -.;r :ADITYA BIRLA
before concluding a sale. Trademark/LogoAditya Birla Capital is owned by Aditya Birla Management Corporation Private bJr __ lI.l CAPITAL
Limited and Trademark/logo HealthReturp.s,Healthy Hearl Score and Active Dayz are owned by MMI Group Limited. ddll\ .rhu-lncapita l com
These trademark/Logos are being used by Aditya Birla Health Insurance Co. Limited under licensed user agreement(s).
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Application Number: _
We acknowledge with thanks the receipt of your application and amount by Cash/Cheque/Demand Draft/ Others of amount of
Rs. dated drawn on . Neither the submission to Us of a completed
proposal for insurance nor any payment for any policy sought obliges Us to agree to issue a policy, which decision is and always shall be in our sole and absolute discretion.
If We accept a proposal for insurance, it shall be subject to the policy terms and conditions and We shall have no liability whatsoever if premlumis not received by Us in full
and in time or is not realized. If We do not accept the proposal, We will inform you and refund the payment, post deduction of applicable pre-policy check up charges if any,
received from you without interest.'We do not have any liability of claim until the proposal is accepted by us,. counter offer if any accepted by you & policy is issued'.

Signature of Branch Official: -------

Name of the Branch Official : ---------~-----------
04
Date: _