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    Shikhar Insurance Company LTD

    Uploaded by

    Samsher Ali
    This document contains a health insurance proposal form for Shikhar Insurance Company Ltd. The form requests individual details such as name, date of birth, address, contact information, gender, citizenship ID, sum insured, period of insurance, and details of any pre-existing diseases for the proposer and any insured family members. The proposer is required to declare that the information provided is true and accurate. The proposal form must be signed and photos attached for all individuals covered under the proposal.

    Copyright:

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

    Shikhar Insurance Company LTD

    Uploaded by

    Samsher Ali
    67 views2 pages
    This document contains a health insurance proposal form for Shikhar Insurance Company Ltd. The form requests individual details such as name, date of birth, address, contact information, gender, citizenship ID, sum insured, period of insurance, and details of any pre-existing diseases for the proposer and any insured family members. The proposer is required to declare that the information provided is true and accurate. The proposal form must be signed and photos attached for all individuals covered under the proposal.

    Original Description:

    Health

    Original Title

    Health-Proposal1

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    This document contains a health insurance proposal form for Shikhar Insurance Company Ltd. The form requests individual details such as name, date of birth, address, contact information, gender, citizenship ID, sum insured, period of insurance, and details of any pre-existing diseases for the proposer and any insured family members. The proposer is required to declare that the information provided is true and accurate. The proposal form must be signed and photos attached for all individuals covered under the proposal.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    67 views2 pages

    Shikhar Insurance Company LTD

    Uploaded by

    Samsher Ali
    This document contains a health insurance proposal form for Shikhar Insurance Company Ltd. The form requests individual details such as name, date of birth, address, contact information, gender, citizenship ID, sum insured, period of insurance, and details of any pre-existing diseases for the proposer and any insured family members. The proposer is required to declare that the information provided is true and accurate. The proposal form must be signed and photos attached for all individuals covered under the proposal.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Shikhar Insurance Company Ltd.

    Head Office: Shikhar Biz Centre, Thapathali


    P. O. Box: 11133, Kathmandu, Nepal
    Tel: 4246101, 4246102 , Fax: 977-1-4246103
    E-mail: [email protected], Web: www.shikharinsurance.com

    HEALTH INSURANCE PROPOSAL


    Kindly provide the following details in Block Letters:
    Individual Information
    A. Full Name of the Proposer :

    B. Date of Birth :

    C. Address of the Proposer :

    D. Telephone no :

    E. Mobile no :

    F. E-mail id :

    G. Gender :

    H. Citizenship ID Card no :

    I. Sum Insured :

    J. Period of Insurance : From Date : To Date :

    K. Details of Insured for Floater option

    S.N Insured Person Relationship Date of Birth Gender Sum Insured

    5
    L. Details of any pre-existing disease/Health declaration
    S.N. Insured Name Detail of illness Year

    Declaration and undertaking by the Proposer

    We do hereby declare that the above statements, answers & particulars are true to the best of our knowledge & brief and that we
    have not withheld any information what so ever regarding the proposal. We agree that this proposal & declaration shall be the basis
    of the contract between us & Shikhar Insurance Company Ltd. whose policy for the insurance proposed is accepted by us.
    We further agree that if, after insurance is affected, it is found that any of the above statements, answers or particulars are incorrect
    or untrue in any respect, we shall have no liability under this insurance. The company will not be on risk until the proposal has been
    accepted and full payment of the premium made as per agreed schedule. Persons who are to be insured under the policy may have
    to undergo Medical examinations prior to the acceptance of the proposal as per company guidelines. The liability of Shikhar
    Insurance Company Ltd. commences only upon the acceptance of this proposal notwithstanding the payment of any deposit.
    We agree & undertake to convey to Shikhar Insurance Company Ltd. any additions / alterations carried out in the risk proposed
    for insurance after submission of this proposal form.

    Place :
    Date : Proposer’s Signature Photo

    Please provide photo for each person under this proposal


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    E-mail: [email protected], Web: www.shikharinsurance.com

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