United India Insurance Company Limited

Corporate Identity Number: U93090TN1938GOI000108

Registered Office: 24 Whites Road, Chennai – 600014
IRDAI REG NO.545

Family Medicare Policy

Proposal Form
Important Instructions Please read the instructions below carefully before filling out this form
• This Proposal Form shall be the basis of the policy to be issued. Thus, please provide all the information sought in this Proposal Form & all
additional relevant information fully & accurately. Please do not leave any space blank or put dashes.
• The Company will not be on risk until the Proposal has been accepted by the Company and communication of the acceptance has been given
to the proposer in writing after payment of requisite premium.
• Details of up to 6 Insured Persons, can be filled in this Proposal Form. For additional members, please use a fresh form.
• Pre-policy health check-up reports not older than 30 days are required to be submitted, wherever required at Company’s discretion.
• A person porting (switching) from health insurance policy of other non-life insurance or stand-alone health insurance companies must
complete Annexure C (Portability Form) along with Proposal Form, Annexure A and B (if required).
• List of documents required is provided in Annexure D.

I. Proposer Details Please submit a copy of Aadhaar/Passport/Election Photo ID Card/Latest Electricity Bill/Bank Pass Book as Proof of Address

Name:

Date of Birth: DD/MM/YYYY Gender: ☐ Male ☐ Female ☐ Other Marital Status: ☐ Single ☐ Married

Occupation: ☐ Salaried ☐ Self-Employed ☐ Others, please specify

PAN: Aadhaar Card/Passport No: E-Insurance Account No.:

(Or form 60/61) (if available)

Address:

City: State: Pin Code:

Tel. No.: Email ID: Mobile:

II. Nomination Where Nominee is a minor, please give the details of Appointee

Nominee mentioned below will be for the 1st Insured. For other members covered under the Policy, the 1st insured is deemed to be the Nominee

Nominee Name: Nominee Relationship with the Proposer:

Nominee Address:
Nominee Date of Birth: Nominee Contact No:

III. Coverage Details Coverage required from DD/MM/YYYY to midnight of DD/MM/YYYY

Policy Type: ☐ Individual Sum Insured ☐ Family Floater TPA preference:

Sum Insured Options: ☐ 3 Lakhs ☐ 4 Lakhs ☐ 5 Lakhs ☐ 6 Lakhs ☐ 7 Lakhs ☐ 8 Lakhs
☐ 9 Lakhs ☐ 10 Lakhs ☐ 15 Lakhs ☐ 20 Lakhs ☐ 25 Lakhs
Daily Cash Allowance (Opt.): ☐ Yes ☐ No Maternity Expenses and New Born Baby Cover (Opt.): ☐ Yes ☐ No

IV. Insured Person(s) Details Paste one stamp size photograph and sign below. In case of minor, guardian or proposer may sign

1st Insured 2nd Insured 3rd Insured 4th Insured 5th Insured 6th Insured
Person’s Photo Person’s Photo Person’s Photo Person’s Photo Person’s Photo Person’s Photo

Signature Signature Signature Signature Signature Signature

1
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited
Corporate Identity Number: U93090TN1938GOI000108
Registered Office: 24 Whites Road, Chennai – 600014
IRDAI REG NO.545

1st Insured Person 2nd Insured Person 3rd Insured Person 4th Insured Person 5th Insured Person 6th Insured Person

Name

Date of Birth DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY

Gender ☐M☐F☐O ☐M☐F☐O ☐M☐F☐O ☐M☐F☐O ☐M☐F☐O ☐M☐F☐O

Marital Status ☐ Single ☐ M ☐ Single ☐ M ☐ Single ☐ M ☐ Single ☐ M ☐ Single ☐ M ☐ Single ☐ M
ABHA ID
Occupation
Aadhaar No.
Sum Insured
Height (cm)
Weight (kg)
Blood Group
Relation w/ Proposer
Dependent ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

ABHA Creation Declaration: I declare that I have read the terms of usage of Aadhar for creation of ABHA Number as available at
https://healthid.ndhm.gov.in/register/aadhaar. I consent to the usage of my/our Aadhaar Number(s) by UIIC for creation of my/our ABHA number(s) through
National Health Authority (NHA). ` ☐ Yes ☐ No

V. Existing Health Cover Information

Does any person proposed to be insured presently hold a health insurance policy from any insurer (including UIIC)? ` ☐ Yes ☐ No
If yes, please give details below.
Insured Person 1 Insured Person 2 Insured Person 3 Insured Person 4 Insured Person 5 Insured Person 6

Company
Policy No.
Policy Type (Base/ Top-Up)
Expiry Date
Sum Insured
Servicing TPA
Last Claimed Date
Claimed Amount
Porting/Migrating

Kindly fill Annexure C if insured is porting from another insurance company to our company.
Please note that the continuity of benefits shall NOT be considered if the above question is not replied in the affirmative, details are not provided and Portability
Form (Annexure C) and relevant supporting documents are not submitted to UIIC.

VI. Medical Information

Medical History of the person proposed for Insurance. Tick Yes/No. Please do not leave the spaces blank.

Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6

Are/Is you/the person proposed for insurance in good health and free
from physical and mental disease or infirmity or medical complaints Y N Y N Y N Y N Y N Y N
e e e e e e e e e e e e
s s s
Lifestyle Questionnaire s s s s s s s s s
Does any person who is proposed for insurance consume
Alcohol
Tobacco (Cigarette/Bidi/Gutkha/Pan Masala, etc.)
Illegal Drugs

If the answer is ‘Yes’ to any of the questions above, please give details below on the type and quantity consumed per week and consumption history (years)
➢ Alcohol –
➢ Tobacco (Bidi/Cigarette/Gutkha/Pan Masala, etc.) –
➢ Illegal Drugs –

2
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited
Corporate Identity Number: U93090TN1938GOI000108
Registered Office: 24 Whites Road, Chennai – 600014
IRDAI REG NO.545

Specific Condition Questionnaire - I

Does any person who is proposed for insurance ever suffered from/are suffering from any of the following: Please provide details in the table below.

Genetic Disorder, Malignant Cancer, Permanent Recurring Condition,

HIV/AIDS Y N Y N Y N Y N Y N Y N
e e e e e e e e e e e e
Acid Attack, Anaemia, Asthma, Blindness, Mental illness s s s s s s s s s s s s
Diabetes Mellitus, Hypertension, Renal stones
Epilepsy, Chronic neurological conditions, Parkinson’s Disease,
Multiple Sclerosis, Muscular Dystrophy, Cerebral palsy
Sickle Cell Disease, Thalassemia, Haemophilia Y N Y N Y N Y N Y N Y N
Low vision, Hearing Impairment, Dwarfism, Autism Spectrum disorder, e e e e e e e e e e e e
Leprosy cured person
Specific Learning Disability, Speech & Language Disability, Intellectual s s s s s s s s s s s s
disability, locomotor disability

Specific Condition Questionnaire - II

Does any person who is proposed for insurance ever suffered from/are suffering from any of the following: Please provide details in the table below
Any disorder/ disease of the stomach, Intestine, Liver, Gall bladder,
Pancreas, Kidney (except Renal Stones), Urinary Bladder, Urinary Tract Y N Y N Y N Y N Y N Y N

Blood Disorder, Venereal Diseases (other than above),

Hyperthyroidism, Hypothyroidism, Dyslipidaemia (High cholesterol) Y N Y N Y N Y N Y N Y N

Cataract or other diseases of the eye Y N Y N Y N Y N Y N Y N

Critical Illness, Recurring Illness or Chronic Illness Y N Y N Y N Y N Y N Y N

Disease of Bones/ Joint including arthritis, rheumatic pain, slipped disc,

spinal disorder, injury to Ligaments or Paralysis Y N Y N Y N Y N Y N Y N

Disease of Fistula/Prostrate, Piles, Hernia, Varicose veins Y N Y N Y N Y N Y N Y N

Disease of Cardiovascular system, heart disease (Chest Pain, Coronary

Insufficiency, Myocardial Infarction, etc.) Y N Y N Y N Y N Y N Y N

ENT Disease, Respiratory or Allergic Disease (Tuberculosis, Bronchitis,

Pneumonia, COPD etc) other than Asthma Y N Y N Y N Y N Y N Y N

Gynaecological disorder such as DUB, Fibroid Uterus, Prolapsed

Uterus, Ovarian cyst or breast or any specific gynaecological disorders Y N Y N Y N Y N Y N Y N
or have undergone caesarean/ Hysterectomy

Disease of Central Nervous System (other than those mentioned in

Specific Condition Questionnaire) Y N Y N Y N Y N Y N Y N

Psychiatric Disorder (other than those mentioned in Specific Condition

Questionnaire), Thyroiditis/Goitre Y N Y N Y N Y N Y N Y N

Benign Tumor, Pre-cancerous Lesion, Ulcer, boil, cyst or wound etc.

which does not heal or improve despite treatment Y N Y N Y N Y N Y N Y N

Other Medical Questionnaire

Does any person who is proposed for insurance ever suffered from/are suffering from any of the following: Please provide details in the table below
More than two Hospitalization in the previous two years except for
hospitalizations for vector-borne, air-borne, and water-borne diseases
with hospitalizations less than 5 days.
Or Y N Y N Y N Y N Y N Y N
Any Surgery/Treatment, consultations, investigations, or diagnostic
tests planned or pending

Experienced pain for more than 7 days in any part of the body OR
restriction of any movement OR difficulty in swallowing or breathing
OR any difficulty in carrying out your daily activities?
Or Y N Y N Y N Y N Y N Y N

Persistent headache or persistent cough OR blood in stool or any

bleeding from any other orifice/ body opening for more than 5 days?

If you answered ‘Yes’ to any of the prior questionnaires, please give details in the following table. Additionally, also submit Annexure A, B.

3
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited
Corporate Identity Number: U93090TN1938GOI000108
Registered Office: 24 Whites Road, Chennai – 600014
IRDAI REG NO.545

Date of Last
Name of the Person Treatment(s) Name of the Hospital Name
Illness(es) Consultation Present Status
to be insured Undergone treating Doctor & Phone No.
(DD/MM/YYYY)

Past Proposals

Has any proposal for life, health, or critical illness insurance for any of the persons proposed to be insured ever been declined, postponed,
loaded, or made subject to any special conditions by any insurance company? ☐ Yes ☐ No

VII. Payment Details

Premium Amount (₹): (in words)

Premium Payment Modes: ☐ Cash ☐ Cheque ☐ DD ☐ Credit/Debit Card ☐ ECS Cheque/DD No.: Date: DD/MM/YYYY

VIII. Bank Details for Processing of Refund

Bank Name: Branch Address:
Bank Account No: IFS Code:

4
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited
Corporate Identity Number: U93090TN1938GOI000108
Registered Office: 24 Whites Road, Chennai – 600014
IRDAI REG NO.545

IX. 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 respects to the best of my knowledge and that I am authorized to propose on behalf of these 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 requisite receipt.
☐ I further declare that I will notify in writing any change 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 I consent to the company seeking medical information from any doctor or 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 underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
☐ Ayushman Bharat Health Account (ABHA) Declaration: I authorize the company to access my/our information as available in my/ our
Ayushman Bharat Health Account (ABHA) including the medical records for the sole purpose of proposal underwriting and/or claims settlement
and share the same with TPAs, Service Provider(s) of UIIC and/or any Governmental and/or Regulatory authority and/or to comply with the
applicable Law/ Regulations.

I also confirm that the source of funds for premium paid under this policy is legal.
Date: DD/MM/YYYY Place: Signature of the Proposer:
Name of the Proposer (in BLOCK letters):

X. Certificate from Proposer in case Proposal form is not filled by them/The proposer signs in vernacular language/is illiterate
(As required to comply with clause no. 6 (4) of Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests) Regulations, 2017)
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.
Date: DD/MM/YYYY Place: Signature of the Proposer:
Name of the Proposer (in BLOCK letters):
Please note that this should necessarily be signed by the proposer and not by his/her representative.
XI. Declaration of the Intermediary
I/We confirm that I/We have explained the product features to the proposer and its suitability to him/her and other insured persons.

Date: DD/MM/YYYY Place: Signature of Intermediary:

XII. Statutory Warning (Section 41 of Insurance Act, 1938 – Prohibition of Rebates)

• 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.
• Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakh rupees.

XIII. Office Use Only

Gross Premium: Premium for Optional Cover: Net Premium:

Intermediary Code: Development Officer Code:

Acknowledgement by the Company Date: DD/MM/YYYY

We acknowledge the receipt of your proposal and amount by Cash/Cheque/Others for amount of Rs.
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 to make any payment if premium is 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 any payment received from you without interest within next 30 days.

5
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited Annexure – A

This Annexure is to be completed by EACH insured person who has answered ‘Yes’ to any of the questions in Section V (Medical History) or
has any pre-existing conditions/adverse history in respect of any illness.

Name of Insured Person:

Diabetes Questionnaire

• Date of 1st Diagnosis of Diabetes :

• Do you take any anti-diabetic drugs? :

If so, please give name with dosage
• Please give details of fasting and postprandial blood :
sugar readings, E.C.G. findings & other investigation
reports with date. Please also send reports
• Please state whether you have been diagnosed
with any complication of diabetes? :

Hypertension Questionnaire
• Date of 1st Diagnosis of Hypertension :
• What is your blood pressure reading? :
Please state with dates
• Please state names of anti-hypertensive drugs :
with dosage details
• Are you a smoker? :
• Is it essential/secondary/malignant hypertension? :
• Please state whether you have been diagnosed
with any complication of hypertension? :
• Please give findings of all investigation reports :

Chest Pain or Coronary Insufficiency or Myocardial Infarction Questionnaire

• Date of 1st Diagnosis :
Did you ever suffer from chest pain/coronary
insufficiency/myocardial infarction? If so, please
give diagnosis and date.
• Please state the name and dose of drugs you are :
taking at present
• Please state the findings with dates of investigations :
done like ECG, Stress Test, coronary angiography, X-
ray, pathology reports, etc. Please send reports with
the proposal form.
• Please state the date of hospitalisation and names of :
hospitals (attach last discharge summary)
• Please state complications and other related disease, :
if suffered.

• Please state whether you can do your regular work :

and whether you have any limitation of activity?

• Are you advised any special treatment? If so, please :

give information

Any other Pre-Existing Condition

• Nature of illness/disease/injury & treatment received :
• Date of 1st Diagnosis :
• Whether fully cured? :
• Please state the date of hospitalisation and names :
of hospitals. (attach last discharge summary)

Date: DD/MM/YYYY Place: Signature of Insured Person:

6
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited Annexure – B

This Annexure is to be completed by the consulting physician/surgeon if ANY of the insured persons have answered ‘Yes’ to any of the
questions in Section V (Medical History) or have any pre-existing conditions/adverse history in respect of any illness.

• Name of the Insured Person :

History
• Present complaints and investigation, if any? :

• Any past history of disease, operations, accidents, :

investigations with date, major medical complaints
of hospitalisation?

• Details of present and past medication with duration :

• Is he/she cured of diseases, if any? :

When was your treatment, if any, given, stopped?

• General Examination :

• Systematic Examination :

Signature of Consulting Physician Signature of Proposer

Name of Consulting Physician: Place:

Qualifications: Date: DD/MM/YYYY
Address:

Telephone No:

Office Use Only

Do you consider the risk acceptable?

Competent Authority:

At Operating Office:

At Regional Office (If referred to RO):

7
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited Annexure – C

This Annexure is to be completed by the policyholder who is porting from a health insurance policy issued by another insurance company

Name of Policyholder:

Policy No:

PORTABILITY FORM

1. Name of the Insured(s)

2. Date of Birth
3. Address of the Policyholder

4. Details of Existing Insurer

a. Name of insurance company
b. Sum Insured
c. Cumulative Bonus
d. Add-ons/riders taken
e. Policy Number
5. Details of the Proposed Insurance
a. Name of the product proposed/intended to take
b. Sum Insured proposed
c. 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

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

• 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 the Disease / Treatment Waiting Period in Days / Years

1.
2.
3.
4.

Date: DD/MM/YYYY Place: Signature of Policyholder:

8
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1
United India Insurance Company Limited Annexure – D

This Annexure details the list of documents that are required along with this proposal form and the documents that are considered as valid.

Documents Required

• Completed Proposal Form

• Cancelled Cheque (supporting bank account details)
• Stamp Size Photograph (2 no.) for each insured person
• Pre-Policy Check-up reports (if applicable)
• Copy of existing health insurance policies (if applicable)
• Proof of Identity (any one document listed below)
• Proof of Residence (any one document listed below)
• 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
Proof of Identity 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
Corruption Act, 1988’) verifying the identity and residence of the customer
vi. Aadhaar Card
vii. Job card issued by NREGA duly signed by an officer of the State Government
Proof of Residence i. Passport
ii. Driving License
iii. Aadhaar Card
iv. Voter’s Identity Card
v. Job card issued by NREGA duly signed by an officer of the State Government
vi. Letter issued by National Population Register containing details of name and address

Where the above documents do not have the updated address, the following documents shall be
deemed to be valid documents for the purpose of Proof of Residence.
i. Utility bill which is not more than two months old of any service provider (electricity, telephone,
post-paid mobile phone, piped gas, water bill)
ii. Property or Municipal Tax receipt
iii. Pension or family pension payment orders (PPOs) issued to retired employees by Government
Departments or Public Sector Undertakings, if they contain the address
iv. Current Photo Passbook with details of permanent/present residence address (updated up to the
previous month)
v. Current statement of bank account with details of permanent/present residence address (as
downloaded)
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 Written confirmation from the banks where the proposer is a customer, regarding identification and
and Residence proof of residence

9
Family Medicare Policy – Proposal Form
URN: UIIC/FMP/23-24/1