PROPOSAL FORM

National Super Top Up Mediclaim Policy

Proposal for New Policy Renewal (with change in details) FOR OFFICE USE ONLY
Policy Period: From To midnight of Premium (before discounts) :INR _______________
DD MM YY DD MM YY Net Premium :INR ______________
IMPORTANT INSTRUCTIONS Intermediary_____________________________________
(a) This Proposal Form shall be the basis of the policy to be issued. It is Code__________________ Date_______/____/_________
therefore essential that all the information sought in this Proposal Dev. Officer _____________________________________
Form and all additional information relevant to the risk to be Code__________________ Date_______/____/_________
insured is provided fully & accurately. Please do not leave any space
blank, or put dashes. Risk acceptable: Y/ N
(b) The Company will not be on risk until the Proposal have been Competent Authority:
Name ______________________________
accepted by the company and communication of the acceptance has
Designation: ___________
been given to the proposer in writing after full payment of premium. Signature_______________
(c) Details of the proposer and up to 5 insured persons can be filled in Policy No. _________________________________
this Proposal Form. One stamp size photograph of each person are Issuing Office: _______________________________
to be affixed on the Proposal Form. If required, additional forms to Office code: ______________
be attached.
(d) Portability Form is provided in Annexure B.
(e) List of documents required is provided in Annexure C.
(f) List of illnesses permanently excluded if existing at the time of
taking the Policy is provided in Annexure D.
1. PROPOSER / INSURED DETAILS: Mr. Ms. Mrs.
Name: _______________________________________________________________________________________________________________
Occupation/Business/Service/Other: ___________________PAN No: _______________________ Aadhaar No: _______________________
2. ADDRESS / CONTACT DETAILS:
Address: _____________________________________________________________________________________________________________

__________________________________ District: _______________________________State:______________________Pin:______________

Mobile No: _________________________________Email ID: __________________________________________________________________

3. NOMINEE DETAILS:
Name of Nominee: _____________________________________________________________________Date of Birth: dd / mm / yyyy
Relationship with proposer ____________PAN no: _________________Mobile: ____________________Email ID: ______________________
Name of Guardian (if nominee is minor) ___________________________________________Relationship with proposer_________________
4. POLICY DETAILS: (Please strike through the one not required)
Policy Type: Is TPA service required?:
Individual Floater Yes No
5. BANK DETAILS:
Name in Bank Account: ______________________________________________________________________________________________

Bank: __________________________________________________________________________Branch: _____________________________

SB Account No: __________________________________________________ IFSC: _____________________________________________

6. INSURED PERSON DETAILS
No. of persons covered (including proposer) _________ (in figure), __________________________ (in words)
Paste one stamp sized photographs and sign below

Proposer Insured Person Insured Person Insured Person Insured Person Insured Person

All the fields are mandatory. Please do not leave any field blank.

Customer Code
Proposer Insured Insured Insured Insured Insured Insured Insured
Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7
Name
Date of Birth
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 1 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
 (mm/dd/yyyy)
Age
Gender (M/F)
Height (cm)
Weight (kg)
Blood Group
Marital Status
Relationship with
Proposer
Dependent (Y/N)
Occupation
Do you smoke?
(Y/N)
Do you drink
alcohol? (Y/N)
*Threshold
*Sum Insured

* If ‘Policy Type’ is Floater, Threshold and Sum Insured of Proposer shall apply to the entire family.

7. INSURANCE PARTICULARS
Is there an active Base Policy covering any/ all of the insured persons for hospitalisation? Yes/ No
If yes, please give details below and attach policy copies
Policy No. Insurer Floater/ Members covered with SI Policy Expiry Last Claimed Porting?
Ind and CB Name Date Claimed Amount (Y/ N)
Date

8. EXISTING DISEASES OF PROPOSER AND INSURED PERSON

If Proposer/ any Insured Person is/ are diagnosed with any condition, ailment, injury or disease by a physician any time prior to the date
of Proposal or for which medical advice or treatment was recommended by, received from or is being received from a physician,
complete the following table with date of diagnosis. Please do not leave the spaces blank.

a. Existing Lifestyle Diseases

Disease Name Proposer Insured Person 1 Insured Person 2 Insured Person 3 Insured Person 4 Insured Person 5

Diabetes
Hypertension
Cardiac Ailment

b. Existing Diseases, permanently excluded

Insured Insured Insured Insured Insured
Disease Name Proposer
Person 1 Person 2 Person 3 Person 4 Person 5
Sarcoidosis
Malignant Neoplasms
Epilepsy
Heart Ailment, Congenital heart disease and
valvular heart disease
Cerebrovascular disease (Stroke)
Inflammatory Bowel Diseases
Chronic Liver diseases
Pancreatic diseases
Chronic Kidney disease
Hepatitis B
Alzheimer's Disease, Parkinson's Disease
Demyelinating disease
National Insurance Co. Ltd.
National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 2 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
 HIV & AIDS
Loss of Hearing
Papulosquamous disorder of the skin
Avascular necrosis (osteonecrosis)
If any of the above diseases is existing at the time of inception of the Policy, claim for such disease shall not be payable for specified ICD codes as per
Annexure D.
Do you agree: Yes / No Signature:______________________________

c. Pre Existing Diseases

Disease Name Proposer Insured Person 1 Insured Person 2 Insured Person 3 Insured Person 4 Insured Person 5

Above PEDs will be covered after a waiting period of 4 years from inception of Policy.
Do you agree: Yes / No Signature:______________________________

9. PAYMENT DETAILS
Premium Paid by: Cash Cheque DD Others, specify
Amount__________________ Date_____/_____/__________Bank Name
10. DECLARATIONS
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 respect. I consent and authorize the Insurers to I/We hereby declare, on my
behalf and on behalf of all persons proposed to be insured to the best of my knowledge and that I am authorised to propose on
behalf of these other persons.

I understand that the information provided by me will form the basis of the insurance policy, and that the policy will come into force
only after full receipt of the premium chargeable.

I further declare that I/we will notify in writing any change occurring in the occupation or general health of the proposer after the
proposal has been submitted but before communication of the risk acceptance by the company.

I declare that, I consent to the company seeking medical information from any doctor or from a hospital who/ which at any time 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
the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory authority.

If any of the above statements, answers and/or particulars given by me are found to be incorrect any time during the currency of the
Policy, it shall be considered as violation of disclosure of information and the Policy shall be void and all premium paid thereon shall
be forfeited to the Company.

Place: ______________________ ____________________________________

Date: ______________________ Signature of the proposer

11. IN CASE PROPOSAL FORM IS NOT COMPLETED BY PROPOSER

As per clause no. 6.(4) of Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests)
Regulations, 2017, - ‘where, for any reason, the proposal and other connected papers are not filled by the proposer, a certificate may
be incorporated at the end of proposal form from the proposer that the contents of the form and documents have been fully explained
to him/her and that he/she has fully understood the significance of the proposed contract’
CERTIFICATE FROM PROPOSER
The proposal form is filled up by my representative, but the contents of the documents have been fully explained to me and I am
willing to accept the coverage subject to terms, conditions and exceptions prescribed by the Insurance Company therein.

Place : _______________________ ______________________________

Date : ______/_______/__________ Signature

Name of the Proposer (in BLOCK LETTERS) _________________________________________________________

N.B. : This should necessarily be signed by proposer, and not by his/her representative.

12. SECTION 41 OF INSURANCE ACT, 1938 – PROHIBITION OF REBATES (Amended as per The Insurance
Laws (Amendment) Act, 2015
1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or
continue 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 tables of the
Insurers.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten
lakh rupees.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 3 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
 National Insurance Company Limited,
Registered Office: - 3, Middleton Street, Kolkata-700071
IRDA Registration No: 58
CIN U10200WB1906GOI001713
Annexure A

MEDICAL EXAMINATION REPORT PART I: PERSONAL HISTORY

To be completed by consulting physician / surgeon in case of adverse medical history

1 Name of the Insured Person

:
2 History

(a) Present complaints and investigation, if any

:

(b) Any past history of disease, operations, accidents,

investigations with date, major medical complaints of :
hospitalisation?
(c) Details of present and past medication with duration
:
(d) Is he cured of diseases, if any?
:
When was your treatment, if any, given, stopped?
:
3 General examination
:
4 Systematic examination
:

Name of Medical Examiner & qualification:

Regd.No:
Address: Signature of Medical Examiner:

Date: Signature of Proposer:

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 4 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
 Annexure B
Policy No. :
Name of Insured Person :

To be completed by the insured in case of porting from a health insurance policy issued by another insurance company

Portability Form
1) Name of the Policyholder / insured (s)
2) Date of Birth/Age
3) Address of the policyholder/insured

4) Details of existing insurer

i. Name of insurance company
ii. Name of the product
iii. Sum Insured
iv. Cumulative Bonus
v. Add-ons/riders taken
vi. Policy number
5) Details of the proposed insurance
i. Name of the product proposed/intend to take
ii. Sum Insured Proposed
iii. Whether Cumulative Bonus to be converted
to an enhanced sum insured
6) Reason(s) for Portability
7) No. of family members to be included in the
policy to be ported

Enclosure: Photocopy of the existing & previous policy documents

Date:
Signature of the policyholder

1. Whether the PED exclusions / time bound exclusion have longer exclusion period than the existing policy? (Please
indicate Yes / NO):

2. If yes, please give written consent to the declaration below:

I am aware that the waiting period for the following disease(s)/treatment(s) is more than the previous policy terms. I
hereby agree to observe the additional waiting period for the following disease(s)/treatment(s).

Name of disease/ treatment Waiting period in days/ years

1.
2.
3.
4.

Place : _____________________________________
Date : Signature of the policyholder

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 5 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
National Insurance Co. Ltd. Annexure C
Documents required
1. Completed proposal form
2. Cancelled cheque (supporting bank account details)
3. Stamp size photograph (1 nos) for each insured person
4. Pre policy check up reports (if applicable)
5. Copy of existing health insurance policies (if applicable)
6. Proof of identity (any one document listed below)
7. Proof of residence (any one document listed below)
8. Copy of IT Certificate/ IT Return (wherever applicable)
9. Pan Details (in case PAN not available, Form 60 or 61 as per Rule 114B of the Income-tax Rule,1962 must be submitted)

Documentary proof
Features Documents
i. Passport
ii. PAN Card
iii. Voter’s Identity Card
iv. Driving License
v. Letter from a recognized Public Authority (as defined under Section 2 (h) of the Right to
Information Act, 2005) or Public Servant (as defined in Section 2(c) of the ‘The Prevention of
Proof of identity
Corruption Act, 1988’) verifying the identity and residence of the customer
vi. Personal identification and certification of the employees of the insurer for identity of the
prospective policyholder.
vii. Letter issued by Unique Identification Authority of India containing details of name, address and
Aadhar number
viii. Job card issued by NREGA duly signed by an officer of the State Government
i. Telephone bill pertaining to any kind of telephone connection like, mobile, landline, wireless, etc.
provided it is not older than six months from the date of insurance contract
ii. Current Passbook with details of permanent/present residence address (updated upto the previous
month)
iii. Current statement of bank account with details of permanent/present residence address (as
downloaded)
iv. Letter from any recognized public authority
Proof of Residence
v. Electricity bill
vi. Ration card
vii. Valid lease agreement along with rent receipt, which is not more than three months old as a
residence proof
viii. Employer’s certificate as a proof of residence (Certificates of employers who have in place
systematic procedures for recruitment along with maintenance of mandatory records of its
employees are generally reliable)
Proofs of both Identity and Written confirmation from the banks where the proposer is a customer, regarding identification and proof
Residence of residence.

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 6 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071
 National Insurance Co. Ltd. Annexure D
List of illnesses permanently excluded if existing at the time of taking the Policy
Sl Existing Disease ICD Code Excluded
1 Sarcoidosis D86.0-D86.9
2 Malignant Neoplasms C00-C14 Malignant neoplasms of lip, oral cavity and pharynx, • C15-C26 Malignant neoplasms of digestive organs, • C30-
C39 Malignant neoplasms of respiratory and intrathoracic organs• C40-C41 Malignant neoplasms of bone and articular
cartilage• C43-C44 Melanoma and other malignant neoplasms of skin • C45-C49 Malignant neoplasms of mesothelial and
soft tissue • C50-C50 Malignant neoplasms of breast • C51-C58 Malignant neoplasms of female genital organs • C60-C63
Malignant neoplasms of male genital organs • C64-C68 Malignant neoplasms of urinary tract • C69-C72 Malignant
neoplasms of eye, brain and other parts of central nervous system • C73-C75 Malignant neoplasms of thyroid and other
endocrine glands • C76-C80 Malignant neoplasms of ill-defined, other secondary and unspecified sites • C7A-C7A Malignant
neuroendocrine tumours • C7B-C7B Secondary neuroendocrine tumours • C81-C96 Malignant neoplasms of lymphoid,
hematopoietic and related tissue• D00-D09 In situ neoplasms • D10-D36 Benign neoplasms, except benign neuroendocrine
tumours • D37-D48 Neoplasms of uncertain behaviour, polycythaemiavera and myelodysplastic syndromes • D3A-D3A
Benign neuroendocrine tumours • D49-D49 Neoplasms of unspecified behaviour
3 Epilepsy G40 Epilepsy
4 Heart Ailment Congenital I49 Other cardiac arrhythmias, (I20-I25)Ischemic heart diseases, I50 Heart failure, I42Cardiomyopathy; I05-I09 - Chronic
heart disease and valvular rheumaticheart diseases. • Q20 Congenital malformations of cardiac chambers and connections • Q21 Congenital
heart disease malformations of cardiac septa • Q22 Congenital malformations of pulmonary and tricuspid valves • Q23 Congenital
malformations of aortic and mitral valves • Q24 Other congenital malformations of heart • Q25 Congenital malformations of
great arteries • Q26 Congenital malformations of great veins • Q27 Other congenital malformations of peripheral vascular
system• Q28 Other congenital malformations of circulatory system • I00-I02 Acute rheumatic fever • I05-I09 • Chronic
rheumatic heart diseases Nonrheumatic mitral valve disorders mitral (valve): • disease (I05.9) • failure (I05.8) • stenosis
(I05.0). When of unspecified cause but with mention of: • diseases of aortic valve (I08.0), • mitral stenosis or obstruction
(I05.0) when specified as congenital (Q23.2, Q23.3) when specified as rheumatic (I05), I34.0Mitral (valve) insufficiency •
Mitral (valve): incompetence / regurgitation - • NOS or of specified cause, except rheumatic, I 34.1to I34.9 - Valvular heart
disease.
5 Cerebrovascular disease I67 Other cerebrovascular diseases, (I60-I69) Cerebrovascular diseases
(Stroke)
6 Inflammatory Bowel K 50.0 to K 50.9 (including Crohn's and Ulcerative colitis)
Diseases K50.0 - Crohn's disease of small intestine; K50.1 -Crohn's disease of large intestine; K50.8 - Other
Crohn's disease; K50.9 - Crohn's disease,
unspecified. K51.0 - Ulcerative (chronic) enterocolitis; K51.8 -Other ulcerative colitis; K51.9 - Ulcerative colitis,unspecified.
7 Chronic Liver diseases K70.0 To K74.6 Fibrosis and cirrhosis of liver; K71.7 - Toxic liver disease with fibrosis and
cirrhosis of liver; K70.3 - Alcoholic cirrhosis of liver; I98.2 - K70.-Alcoholic liver disease; Oesophagealvarices in diseases
classified elsewhere. K 70 to K 74.6 (Fibrosis, cirrhosis, alcoholic liver disease, CLD)
8 Pancreatic diseases K85-Acute pancreatitis; (Q 45.0 to Q 45.1) Congenital conditions of pancreas, K 86.1 to K 86.8 - Chronic pancreatitis
9 Chronic Kidney disease N17-N19) Renal failure; I12.0 - Hypertensive renal disease with renal failure; I12.9 Hypertensive renal disease without renal
failure; I13.1 - Hypertensive heart and renal disease with renal failure; I13.2 - Hypertensive heart and renal disease with both
(congestive) heart failure and renal failure; N99.0 - Post procedural renal failure; O08.4 - Renal failure following abortion and
ectopic and molar pregnancy; O90.4 - Postpartum acute renal failure; P96.0 - Congenital renal failure. Congenital
malformations of the urinary system (Q 60 to Q64), diabetic nephropathy E14.2, N.083
10 Hepatitis B B16.0 - Acute hepatitis B with delta-agent (coinfection) with hepatic coma; B16.1 – Acute hepatitis B with delta-agent
(coinfection) without hepatic coma; B16.2 - Acute hepatitis B without delta-agent with hepatic coma; B16.9 –Acute hepatitis
B without delta-agent and without hepatic coma; B17.0 - Acute delta-(super) infection of hepatitis B carrier; B18.0 -Chronic
viral hepatitis B with delta-agent; B18.1 -Chronic viral hepatitis B without delta-agent;
11 Alzheimer's Disease, G30.9 - Alzheimer's disease, unspecified; F00.9 -G30.9Dementia in Alzheimer's disease, unspecified, G20 - Parkinson's
Parkinson's Disease disease.
12 Demyelinating disease G.35 to G 37
13 HIV & AIDS B20.0 - HIV disease resulting in mycobacterial infection; B20.1 - HIV disease resulting in other bacterial infections; B20.2 -
HIV disease resulting in cytomegaloviral disease; B20.3 - HIV disease resulting in other viral infections; B20.4 - HIV disease
resulting in candidiasis; B20.5 - HIV disease resulting in other mycoses; B20.6 - HIV disease resulting in Pneumocystis
carinii pneumonia; B20.7 - HIV disease resulting in multiple infections; B20.8 - HIV disease resulting in other infectious and
parasitic diseases; B20.9 - HIV disease resulting in unspecified infectious or parasitic disease; B23.0 - Acute HIV infection
syndrome; B24 - Unspecified human immunodeficiency virus [HIV] disease
14 Loss of Hearing H90.0 - Conductive hearing loss, bilateral; H90.1 - Conductive hearing loss, unilateral with unrestricted hearing on the
contralateral side; H90.2 - Conductive hearing loss, unspecified; H90.3 - Sensorineural hearing loss, bilateral; H90.4 -
Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side; H90.6 - Mixed conductive and
sensorineural hearing loss, bilateral; H90.7 - Mixed conductive and sensorineural hearing loss, unilateral with unrestricted
hearing on the contralateral side; H90.8 - Mixed conductive and sensorineural hearing loss, unspecified; H91.0 - Ototoxic
hearing loss; H91.9 - Hearing loss, unspecified
15 Papulosquamous disorder L40 - L45 Papulosquamous disorder of the skin including psoriasis lichen planus
of the skin
16 Avascular necrosis
M 87 to M 87.9
(osteonecrosis)

National Insurance Co. Ltd.

National Super Top Up Mediclaim Policy
Regd. Office 3, Middleton Street, Post Page 7 of 7
UIN: NICHLIP21167V032021
Box 9229, Kolkata 700 071