UBI LCV GC-360 - RINN SURAKSHA APPLICATION FORM (07th MAY)

O
Application Form - ‘Group Care 360 ’

(Union Rinn Suraksha scheme for customers of Union Bank of India)
Customer ID : Policy Tenure* : 5 years 4 years 3 years 2 years 1 years
Loan Account No : Loan Tenure :
Loan Amount : LG/MO Code :

Please mention your PF number
Union Rinn Suraksha - Plan 1 (A) : Plan 1 (A) with CI : Union Rinn Suraksha - Plan 1 (B) :
Union Rinn Suraksha - Plan 2 (A) : Plan 2 (A) with CI : Union Rinn Suraksha - Plan 2 (B) :
E
Union Rinn Suraksha - Plan 3 : Plan 3 with CI : Union Rinn Suraksha - Plan 4 : Plan 4 with CI :
Union Rinn Suraksha - Plan 5 (A) : Plan 5 (A) with CI : Union Rinn Suraksha - Plan 5 (B) : Plan 5 (B) with CI :
Union Rinn Suraksha - Plan 6 : Union Rinn Suraksha - Plan 7 :
L
Union Rinn Suraksha - Plan 8 : Union Rinn Suraksha - Plan 9 :
Proposer Details
Mr. Ms. Gender : M F
P
Name :
(First Name) (Last Name)
Address :
Landmark : _____________________________________ City :
M
State : Pin Code :
Date of Birth : / / (DD/MM/YYYY)
Landline : - Mobile :
A
E-mail :
Nominee Details
S
(A) I do hereby authorize Union Bank of India to pay premium amount mentioned above on my behalf, to Care Health Insurance Limited
(Account No: 307801010918234), as premium towards issuance of a certificate of insurance against this application for Group Care 360O - Union Rinn
Suraksha Scheme.
(B) I understand that the Cover offered is under the Union Rinn Suraksha Scheme of Group Care 360O Product designed for Union Bank of India customers.
The scheme is underwritten, administered and serviced by Care Health Insurance Limited (IRDAI Registration No. 148). I further understand that
Union Bank of India is not involved in settlement of claims and I shall directly pursue any of our dispute/claim with the Insurer.
I declare that all the information which is relevant to this Application Form has been disclosed and not withheld. I further declare and agree that this declaration and
the answers given above shall be held to be promissory and shall be the basis of the contract between me and the Insurer.
Name of Applicant : _______________________________________________ Signature :_______________________ Date_______________
Insured Details
Name Date of Birth Gender Height & Weight Relationship
with Applicant
Insured 1 : (DD/MM/YY) M F cms kgs
Note: Incase of multiple members cover will be offered only on floater basis.
Care Health Insurance Limited

Registered Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road,Sector-43, Gurugram-122009
(Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN: RHIHLGP20126V011920 IRDAI Registration No. - 148.
Good Health Declaration
I declare that I have never been diagnosed with or been under treatment for any disability, deformity, terminal illness or any illness/ disease restricting activities (eg
Epilepsy/Seizure disorder). My nature of duties/Occupation does not require me to be involved in any hazardous activity, operating heavy machinery, handling
hazardous material (chemicals/poisons/toxins/ explosives/radioactive materials), working at heights or underground, oil rigging, high voltage, high temperature,
working in aircrafts or sea going vessels, operating arms and ammunitions, employment with armed forces or engaging in adventurous sports.
Yes No
If No please specify details __________________________________________
Name of Applicant __________________________________ Signature_______________________________ Date_______________________
Benefit Table
Particulars Plan 1(A) Plan -1(B) Plan 2 (A) Plan 2 (B) Plan 3 Plan 4 Plan 5 (A) Plan 5 (B)
Sum Insured Rs.5 Lakhs Rs.5 Lakhs Rs.10 Lakhs Rs.10 Lakhs Rs.25 Lakhs Rs.50 Lakhs Rs.2.5 Lakhs Rs.2.5 Lakhs
Entry Age 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years
Policy Tenure Up to 5 years Up to 5 years Up to 5 years Up to 5 years Up to 5 years Up to 5 years Up to 5 years Up to 5 years
Features
Accidental Death Equals to SI Equals to SI Equals to SI Equals to SI Equals to SI Equals to SI Equals to SI Equals to SI
Up to 2 times of Up to 2 times Up to 2 times of Up to 2 times Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of
SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD
PTD
Table) Table) Table) Table) Table) Table) Table) Table)
Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of

SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD
PPD
Table) Table) Table) Table) Table) Table) Table) Table)
Accidental
Rs. 2,00,000 Rs.1,00,000 Rs.2,00,000 Rs.2,00,000 Rs.5,00,000 Rs.5,00,000 Rs.25,000 Rs.1,00,000
Hospitalization
Comprehensive Rs.1,00,000 Rs.50,000 Rs.1,00,000 Rs.50,000 Rs.1,50,000 Rs.1,50,000 NA Rs.25,000
Hospitalization Cover
Hospi Cash Benefit Rs.5,000 for Rs.5,000 for Rs.5,000 for Rs.5,000 for
(Additionally Covid-19 10days NA 10days NA 10days 10days NA NA
Hospitalization)
Child Education Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI
>3 Days & <=8 >3 Days & <=8 >3 Days & <=8 >3 Days & <=8 >3 Days & <=8 >3 Days & <=8
EMI Benefit Cover >3 Days & <=8 >3 Days & <=8
Days: Fixed Days: Fixed Days: Fixed Days: Fixed Days: Fixed Days: Fixed
Days: Fixed Days: Fixed
(for all kinds of Benefit= Benefit= Benefit= Benefit= Benefit= Benefit= Benefit= Benefit=
Hospitalization) Rs.10,000 Rs.10,000> Rs.10,000 Rs.15,000 Rs.15,000 Rs.5,000
Rs.10,000 Rs.1,000
>8 Days & >8 Days & >8 Days &
8 Days & <=13 >8 Days & >8 Days & <= >8 Days & >8 Days & <=13
<=13 <=13 <=13
Days: Fixed <=13 Days: Fixed <=13 Days: Fixed
Days: Fixed Days: Fixed Days: Fixed
Benefit= Days: Fixed Benefit= Days: Fixed Benefit=
Benefit= Benefit= Benefit=
Rs.20,000 Benefit= Rs.20,000 Benefit= Rs.10,000
Rs.20,000 Rs.30,000 Rs.30,000
>13 days: Fixed Rs.20,000 >13 days: Fixed Rs.2,000 >13 days: Fixed
>13 days: Fixed
Benefit= >13 days: Fixed Benefit= >13 days: Fixed >13 days: Fixed >13 days: Fixed Benefit=
Benefit= Benefit=
Rs.30,000 Benefit= Rs.30,000 Benefit= Benefit= Rs.15,000
Rs.30,000 Rs.45,000
Rs.30,000 Rs.45,000 Rs.3,000

• For policy • For policy • For policy • For policy • For policy • For policy • For policy • For policy
Premium tenure: tenure: tenure: tenure: tenure: tenure: tenure: tenure:
Incuding GST 5 years 5 years 5 years 5 years 5 years 5 years 5 years 5 years
Premium: Premium: Premium: Premium: Premium: Premium: Premium: Premium:
`7,299 `6,799 `10,499 `9,999 `16,699 `33,499 `899 `4,499
tenure: tenure: tenure: tenure: tenure: tenure: tenure: tenure:
4 years 4 years 4 years 4 years 4 years 4 years 4 years 4 years
`6,099 `5,599 `9,299 `8,799 `15,799 `31,699 `749 `3,699
`4,799 `4,299 `7,299 `6,799 `12,399 `24,899 `599 `2,849
`3,499 `3,000 `5,099 `4,598 `8,299 `16,699 `349 `1,899
1 year 1 year 1 year 1 year 1 year 1 year 1 year 1 year
`1,999 `1,499 `2,899 `2,399 `4,799 `9,699 `199 `999
Optional Cover - Critical Illness (32 Critical Illnesses Covered)

Plan 1(A) Plan 1(B) Plan 2 (A) Plan 2 (B) Plan 3 Plan 4 Plan 5 (A) Plan 5 (B)
with CI with CI with CI with CI with CI with CI with CI with CI
Premium
Incuding GST • For policy • For policy • For policy • For policy • For policy • For policy
tenure: tenure: tenure: tenure: tenure: tenure:
5 years 5 years 5 years 5 years 5 years 5 years
Premium: Premium: Premium: Premium: Premium: Premium:
`11,599 `23,299 `58,399 `116,899 `2,297 `5,898
• For policy • For policy • For policy • For policy • For policy • For policy
NA NA
`9,599 `19,299 `48,399 `96,899 `1,848 `4,798
`7,499 `15,099 `37,899 `75,899 `1,497 `3,748
`5,299 `10,699 `26,899 `53,899 `948 `2,498
1 year 1 year 1 year 1 year 1 year 1 year
`2,999 `6,099 `15,399 `30,899 `498 `1,298
Benefit Table
Particulars Plan 6 Plan 7 Plan 8 Plan 9
Sum Insured Rs.5 Lakhs Rs.10 Lakhs Rs.25 Lakhs Rs.50 Lakhs
Entry Age 18 – 70 years 18 – 70 years 18 – 70 years 18 – 70 years
Policy Tenure Up to 5 years Up to 5 years Up to 5 years Up to 5 years
Features
Accidental Death Equals to SI Equals to SI Equals to SI Equals to SI
Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of
PTD SI (as per PTD SI (as per PTD SI (as per PTD SI (as per PTD
Table) Table) Table) Table)
Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of
PPD SI (as per PPD SI (as per PPD SI (as per PPD SI (as per PPD
Table) Table) Table) Table)
Child Education Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI
Critical Illness 32 CI 32 CI 32 CI 32 CI
Plan 6 Plan 7 Plan 8 Plan 9
Premium • For policy • For policy • For policy • For policy

Incuding GST
tenure: 5 years tenure: 5 years tenure: 5 years tenure: 5 years
Premium: `5,400 Premium: `10,801 Premium: `27,000 Premium: `54,,000
• For policy • For policy • For policy • For policy
Premium: `4,200 Premium: `8,400 Premium: `21,000 Premium: `42,000
tenure:2 years tenure:2 years tenure:2 years tenure:2 years
tenure: 1 year tenure: 1 year tenure: 1 year tenure: 1 year
* PTD & PPD table will be available on request from any Union Bank of India Branches.
# For Hospitalization benefit, Pre-existing diseases will be covered after four years.
Exclusions
Non-eligible rofessions
• People working in Mines & Oil and Gas Industry. • Furnace Operators.
• Crew Employed In Ships (Merchant Navy when in Duty). • People working underground or at heights.
• Laborers working in the Construction Industry. • People working with Explosives and Firecrackers.
• Professional Sports Persons. • Entertainment Industry workers.
• Airline Cabin Crew including Pilots. • Social services, Religious organizations or charitable (non-profit)
• People Associated with Racing & Adventure Sports Including and not organizations.
limited to River Rafting, Paragliding, Skydiving etc.
• Fire, police or Private Security Guards.
• Armed forces (Army, Navy, Air force including armed guards).
• Chemical Industry Workers.
• Glass workers including Workers working in Glass Furnaces.
Permanent Exclusions
Any Claim in respect of any Insured Member, arising out of or directly or indirectly due to any of the following shall not be admissible, unless expressly stated to the
contrary elsewhere in the Policy:
(a) Any Medical Expenses unless covered by way of an applicable Benefit;
(b) Any illness including any pre-existing condition or its complications except where an Insured Event under Clause 2 or Benefit 1 results from an illness
which arises directly as a consequence of an Injury which is sustained during the Cover Period;
(c) Any pre-existing injury or physical condition;
(d) An Insured Member operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft or Scheduled Airline
or any airline personal;
(e) An Insured Member flying in an aircraft other than as a fare paying passenger in a Scheduled Airline;
(f) Any intentional self- inflicted Injury, suicide or attempted suicide, sexually transmitted conditions, mental or nervous disorders, insanity;
(g) Influence of drugs, alcohol beyond the medically permissible limit or other intoxications or hallucinogens;
Permanent Exclusions
(h) War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections,
mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds;
(I) Participation in actual or attempted felony, riot, civil commotion or criminal misdemeanor;
(j) A complication of infection with Human Immune Deficiency Virus (HIV) or any variance including Acquired Immune Deficiency Syndrome (AIDS) and
AIDS Related Complex (ARC) or venereal disease;
(k) Training for or participating in professional sport of any kind;
(l) Any act resulting in breach of law committed by Insured Member with criminal intent;
(m) The Insured Member serving in any branch of the military, navy, air force or any branch of armed forces or any paramilitary forces;
(n) Radioactive contamination whether arising directly or indirectly ionizing radiation, toxic, explosive or other hazardous properties of nuclear material;
(o) Insured Member working in or with Underground mines, tunneling or explosives or involving electrical installation with high tension supply or conveyance
testing or oil rigs or ship crew services or as jockeys or circus personnel or aerial photography or engaged in any Hazardous Activities as.
(p) Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing
concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
(i) Nuclear attack or weapons mean the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge,
dispersal, release or escape of fissile or fusion material emitting a level of radioactivity capable of causing incapacitating disablement or death.
(ii) Chemical attack or weapons mean the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which,
when suitably distributed, is capable of causing incapacitating disablement or death.
(iii) Biological attack or weapons mean the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms
and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing
incapacitating disablement or death.
In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in
connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above is also excluded;
(q) Resulting from pregnancy or child birth;

(r) Impairment of the Insured Member’s intellectual faculties by abuse of stimulants or depressants or by the illegal use of any solid, liquid or gaseous
substance.
(s) Resulting due to any disease or infection except where such condition arises directly as a consequence of an accident during the Cover period.
Declaration
I ___________________________________, do hereby authorize Care Health Insurance Limited to credit any proceeds against claim (in case of Accidental
Death, Permanent Total Disability & Critical illness) or premium refunds in my loan account no. ___________________ or any other loan financed by Union
Bank of India under the coverage provided through this application.

For Branch Use Only
Transaction ID : _________________________________________ Application No :__________________
Date of Transaction : / / (DD/MM/YYYY)
32 Critical Illness
1 Cancer 2 End Stage Renal Failure

3 Multiple Sclerosis 4 Benign Brain Tumor
5 Parkinson’s Disease 6 Alzheimer’s Disease
7 End Stage Liver Disease 8 Motor Neuron Disorder
9 End Stage Lung Disease 10 Bacterial Meningitis
11 Aplastic Anaemia 12 Pulmonary Thromboembolism
13 Primary(Idiopathic) Pulmonary Hypertension 14 Infective Endocarditis
15 Major Organ Transplant 16 Heart Valve Replacement/repair
17 Surgery of Aorta 18 Cardiomyopathy
19 Surgery for cardiac arrhythmia 20 Angioplasty
21 Balloon Valvotomy/Valvuloplasty 22 Carotid Artery Surgery
23 Coronary Artery Bypass Graft 24 Pericardectomy
25 Surgery to Place Ventricular Assist Devices or Total Artificial Hearts 26 Stroke
27 Paralysis 28 Myocardial Infarction
29 Implantation of Pacemaker of Heart 30 Implantable Cardioverter Defibrillator
31 Major Burns 32 Blindness


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O

Application Form - ‘Group Care 360 ’

Customer ID : Policy Tenure* : 5 years 4 years 3 years 2 years 1 years

Loan Account No : Loan Tenure :

Loan Amount : LG/MO Code :

Landmark : _____________________________________ City :

Date of Birth : / / (DD/MM/YYYY)

Name of Applicant : _______________________________________________ Signature :_______________________ Date_______________

Insured 1 : (DD/MM/YY) M F cms kgs

Care Health Insurance Limited

Name of Applicant __________________________________ Signature_______________________________ Date_______________________

Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of Up to 2 times of

Care Health Insurance Limited

Optional Cover - Critical Illness (32 Critical Illnesses Covered)

Child Education Up to 10% of SI Up to 10% of SI Up to 10% of SI Up to 10% of SI

Plan 6 Plan 7 Plan 8 Plan 9

Premium • For policy • For policy • For policy • For policy

(q) Resulting from pregnancy or child birth;

Name of Applicant __________________________________ Signature_______________________________ Date_______________________

Name of Applicant __________________________________ Signature_______________________________ Date_______________________

Care Health Insurance Limited

Transaction ID : _________________________________________ Application No :__________________

Date of Transaction : / / (DD/MM/YYYY)

1 Cancer 2 End Stage Renal Failure

Care Health Insurance Limited

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Name of Applicant : ___________________________________ Signature :_ Date_____

Name of Applicant __________________ Signature_ Date_________

Name of Applicant __________________ Signature_ Date_________

Name of Applicant __________________ Signature_ Date_________

Transaction ID : _______________________ Application No :