Professional Documents
Culture Documents
Proposal
Proposal
MEDICLASSIC POLICY(INDIVIDUAL)-2020
SHAHLIP22037V062122
Unique Reference No. SHAI/PR0002
Proposer Details :
Name : Yeleswarapu Sridhar Date Of Birth : 10/08/1970
Do you have any other health insurance covering the persons proposed in the past or current?
None
CKYC Identifier
No
Communication Address :
Address Line 1 : S/o Y sita Ramaiah Address Line 2 : 9_277_1. Gowrishankar puram.
Residence Address :
Address Line 1 : S/o Y sita Ramaiah Address Line 2 : 9_277_1. Gowrishankar puram.
Nominee Details 1
Nominee Name : Y Bharthi
Nominee Age : 70
Appointee Details 1
Appointee Name :
Appointee Age :
Appointee Rela- :
tion
Plan Details
Start Date : 28/01/2022 End Date : 27/01/2023
Bank Details
Account Number : Type of Account : Others
IFSC Code :
Insured 1
Relationship with : SELF Name : Yeleswarapu Sridhar
Proposer
Plan : GOLD
Hospital Cash
Cash Benefit of Rs 1000/-for each completed day of Hospitalization subject to a maximum of 7 days per occurrence
and 14 days per policy period is payable. Additional premium applicable.
No
Health History
Do you have any health problems?
None
GST 2398.00
Medical Declaration:
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/ad-
verse medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer's disease/Parkinsons's
disease
No
Agent Declaration:
I / We confirm that the product‘s suitability has been explained to the proposer. The information furnished in the proposal
is true to the best of my knowledge and recommend acceptance of the proposal. (Please Enclose Insurance Agent’s
Confidential Report, If Any)
Yes
Declaration:
I hereby declare, 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 authorised to propose
on behalf of these 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 insurance company and that the policy will come
into force only after full payment of the premium chargeable. I understand that acceptance of the proposal is subject to
evaluation of the proposal by Company's medical team I further declare that I will notify in writing any change occurring
in the occupation or general health of the person proposed for insurance 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 or from
any past or present employer concerning anything which affects the physical or mental health of the person to be
insured and seeking information from any insurer to whom an application for insurance on the person to be insured
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 person to be insured for the sole purpose
of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
Prohibition of rebates:
(Section 41 of the Insurance Act): 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 relation 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 rebate, except such rebate as may be allowed
in accordance with the published prospectuses or tables of the insurer.
Any person making default in complying with the provision of this section shall be liable for a penalty which may extend
to ten lakh rupees.
I also confirm that the source of funds for premium paid under this policy is legal.