Department: Product Development and Underwriting

Creation Date: 23th April 2015

Version: 1.1

PORTABILITY CONSENT FORM

I understand that my application for portability is being processed and some details are being sought from my
current Insurer prior to acceptance of proposed risk. In absence of receipt of the same before expiry of my
existing policy, I authorize CignaTTK Health Insurance Company Limited to process my application based on
the information furnished along with the supporting documents provided herein. However, if any variance is
subsequently found, CignaTTK Health Insurance Company Limited shall at its discretion cancel/ modify my
coverage through appropriate endorsement and/or take these into consideration while adjudicating any claims
under this policy.
I understand that application for Portability to Cigna TTK Health Insurance Company Limited is to be made at
least 45 days before the policy renewal date of current insurance policy. As in this case, the application has
been submitted to CignaTTK Health Insurance Company Limited at a date much closer to the expiry date of
my current policy, there may be a break in the insurance.
Cigna TTK Health Insurance Company Limited is not liable to settle any claim which may arise during such
break.
Acceptance of coverage under Pro Health Insurance will be subject to the Companys Underwriting policy
including Pre Policy Medical Tests (if any).
I also understand that I can extend my existing policy with current insurer to ensure that there is no break in
coverage and shall intimate the same in writing to CignaTTK Health Insurance Company Limited in case of no
written communication regarding acceptance of proposed risk on or before expiry of my existing policy.
I am fully aware that in the event of this Portability Proposal being rejected due to any of the above reasons,
the insurance cover may cease if the grace period for renewal has lapsed. In such a situation all continuity
benefits shall cease.
I am also fully aware that in the event of any Misrepresentation/ Fraud/ Non- disclosure of material facts
discovered post issued of the policy through the IRDA Portability Portal or through the information received from
the previous Insurer; the existing enforced policy will be cancelled and the premium under the policy will be
forfeited.

Proposal No.:

Date of Login:_

Existing Insurance Policy expiry Date:

Proposer Name:

Proposer Sign:

Agent Name:

Agent Sign:_

Date:

Place:_