---- JAGISA ---- chemical companies, plastic or packing industries, life insurance related services

THE ORIENTAL INSURANCE COMPANY LTD.
(Subsidary of General Insurance Corporation of India)
Branch Office: CB5, 6-3-788/A/22, Opp: GoldSpot Street, Ameerpet, Hyd-16.
Tel: 040-2340 27 69, TeleFax:040-2340 09 09.

PROPOSAL FORM FOR MEDICLAIM INSURANCE POLICY

AGENCY CODE :	178 / Mrs.K.Yamini	ANNUAL PREMIUM :	......................................
DEV. OFFICER CODE :	108 / Mr.Suresh	POLICY NO :	......................................

IMPORTANT

a) The Company will not be on risk until the Proposal and Insured Person details have been accepted by the Company and communication of the acceptance has been given to the proposer in writing on full payment of premium.
b) If other family members residing with proposer (i.e. spouse, eligible dependent children and dependent parents) are required to be covered, separate Insured Person Details form should be completed for each of such family members.

PROPOSER DETAILS
1. Name of the proposer:	......................................	........................................	......................................
	(SURNAME)	(NAME)
			FOR OFFICE USE
2. Address and	i) Residence :
Telephone No.	ii) Office :



3. Total number of members to be covered (in figures) (in words)
4. Period of Insurance:	From:.............................	To. .............................	(midnight)

Date:		Signature of the Proposer :

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 out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate on 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 punishable with fine which may extend to five hundred rupees.

INSURED PERSON DETAILS
			POLICY NO :
			INSURED PERSON NO :
			ANNUAL PREMIUM :
To be completed seperately including Questionnaire form for each insured person. (If more than one Insured Person is required to be covered please obtain additional forms from the Company.)
1.Name of the Insured Person		:	FOR OFFICE USE ONLY
2.Address		:



3.Sex (strike out whichever is not applicable)		:
4.Relationship with the Proposer		:
5. Date of Birth and Age		:
6.a)Average monthly income		: Rs.
b) Income Tax PAN No.		:
7.Profession/Occupation/ Trade or Business (Please describe fully with nature of duties)		:
8.Name and address of the Medical Practitioner, his qualifications & Telephone No. if any.		:
		Pin Code Tel. No. State / U. Territory
9.Medical Practitioner's Regn. No.
10.Are you at present or any other time in the past covered under any otherInsurance		:
Type (PA, Cancer Insurance, Hospitalisation Insurance or other Medical Insurance). If so, give particulars of :-
a) Insurer, Policy No. and period of cover, b) Claim Amt. recd. / receivable
Period From To
11.Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium charged if so give details
12. MEDICAL HISTORY TO BE COMPLETED BY THE PROPOSER / INSURED PERSON PLEASE ANSWER THE FOLLOWING QUESTIONS IN YES OR NO (A DASH IS NOT SUFFICIENT) AND GIVE FULL DETAILS IF ANSWER IS YES.,
	12.1 Are you in good health and free from physical and mental disease or infirmity or medical complaints ?
	12.2 If not in good health give full details
13. Have you ever suffered from any of the diseases / illness ?
	If yes, give details
	a) any nervous, mental or psychiatric disease b) slipped disc or other spinal disorder or (fainting episode, blackout, fit) paralysis of any kind. c) high blood pressure, heart diseases, including ischaemic heart disease, other circulatory disorder etc.(rheumatic fever) d) fistula, piles, hernia, varicose veins e) any disease of the bones or joints including rheumatic disease f) disease of uterus, ovaries or breast or any specific gynecological disorders g) any respiratory or allergic disease h) any disorder of the stomach, ulcer, bowel or gall bladder, kidney stones etc. i) any cancer, malignant growth, boil, cyst or wound etc. which does not heal or improve despite treatment j) any other complaint requiring specialist's consultation or surgical or hospital treatment or investigations k) any complaint or tendency that may necessitate such consultation or treatment in the future l) any dimness of vision / cataract m) any disease of ears or difficulty or interference with hearing n) diabetes or any urinary diseases o) any other illness or disease or accident or operation sustained by you
14.	a) Have you ever suffered from dental problems ? Yes / No b) If yes specify same c) When were you treated last for same
15.	Give particulars in table below of any other illness or disease or accident or operation sustained by you in the past.
	Nature of illness / disease injury and treatment, received	Date first treated	Name of attending Medical Practitioner, surgeon with his fully address and Telephone Number	Whether fully cured
	1. 2. 3. 4.



16.	Are there any additional facts affecting the proposed insurance which should be disclosed to Insurers ? ...................................................................
17.	Please give details of any knowledge of any positive existence or presence of any ailment, sickness or injury which may require medical attention
	1. 2. 3. 4.



18.	Please specify Sum Insured opted : Rs. ...........................................
	I hereby declare and warrant that the above statements are true and complete. I consent and authorise the Insurers to seek medical information from any Hospital / Medical Practitioner who has at any time attended or may attend concerning any disease or illness which affects my physical or mental health. I agree that this proposal shall form the basis of the contract should the insurance be effected. If after the insurance is effected, it is found that the statements, answers or particulars stated in the Proposal form and its Questionnaires are incorrect or untrue in any respect, the Insurance Company shall incur no liability under this insurance. I have read the Prospectus and am willing to accept the coverage subject to the terms, conditions and exceptions prescribed by the Insurance Company therein.
	Date : ............./............/.....................		Signature:
	Place :
	NAME OF THE PROPOSER / INSURED PERSON :..................................................... (IN BLOCK LETTERS)
	N.B.: This should necessarily be signed by insured. In case of minor, guardian or proposer may sign.
	FOR OFFICE USE Basic Premium for Scheme Rs. .......................... Family Discount Rs. ........................... Staff Discount Rs. ............................