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: shikharins@mos.com.np, 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: shikharins@mos.com.np, Web: www.shikharinsurance.com

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