7/27/2019 Easy-Travel-Insurance-Proposal-Form.pdf

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10th Fl, Building N. 10, Twe B, DLF City Phase II, DLF Cybe City, Gugan-122002

Easy Tavel InsuancePpsal Fm

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We are under no obligation to accept any proposal or insurance. I we accept a proposal or insurance, it shall be subject to the policy terms and conditions andwe shall have no liability to make any payment i premium is not received by us in ull and in time, or is not realised. Please ll-up this orm in CAPITAL LETTERS.

PROPOSER DETAILS

Proposer : (Mr./Ms./Mrs.)

  First Name Middle name Last Name

 Address:

City/Town: District:

State: PIN Code:

E- Mail:

Contact details (India): Contact details (Overseas):

Nationality :

Proession :  Salaried Sel Employed   Others   Details 

Occupation (nature o duties) :

PLAN DETAIL(S) (Please reer to the brochure or details o benets under plans & select the appropriate option below)

Type:  Individual Family Senior Citizen   Annual Multi-trip 30 days   Annual Multi-trip 60 days Plan: Platinum   Gold  Silver   Bronze    Asian Region Geography: Worldwide   Worldwide excluding USA & Canada    Asia Pacic excluding Japan Proposed Policy Period : From To

PROPOSED INSURED(S) DETAILS: Name o the persons proposed to be insured (including Proposer)

SNo.

Mr./Ms./Mrs. Name o the person to be insured Relationship tothe ProposedInsured

Gender*M/F

Date o Birth( D D M M Y Y )

PassportNumber

12

3

4

5

6

*Gender code M (Male), F (Female)

NOMINEE DETAILS

In the event o the death o an Insured Person any payment due under the Policy will be payable to the Nominee in accordance with the Policy terms and conditions. Please

give below the details o the Nominee, who must be an immediate relative o the Proposer. Nominee or all other persons proposed to be insured shall be the Proposer

Nominee Name Relationship to the Proposed Insured Address o the Nominee

EXISTING INSURANCE DETAILS

Is the proposer or any o the persons proposed, already insured under or proposed or a personal accident insurance policy with Apollo Munich Health or any other

insurance company? I yes, please indicate below the Policy/Application number(s) (Please mention application number incase o pending proposal):

Policy No. / Application No. Insurer From (Date) To (Date) Sum Insured

D D M M Y Y D D M M Y Y  

D D M M Y Y D D M M Y Y  

D D M M Y Y D D M M Y Y  

MEDICAL & LIFE STYLE INFORMATION (i your answer to any o the below is ‘yes’, kindly attach the details in an extra sheet duly signed)

 Are You suering rom or have You ever suered rom any o the ollowing (please encircle): arthritis, allergies, circulatory disorder, cancer o any kind, diabetes,

disorders o the spinal cord or vertebral column like slipped disc etc, disorders o the stomach / large or small intestine, high blood pressure, heart condition, herniao any kind, hemorrhoids, hematological (blood) disorder, mental condition, nervous disorder, ainting episode, blackouts, ts, paralysis o any kind, respiratorydisorder, urinary disorder, varicose veins or any diseases or injury requiring surgical or medical treatment.

I Your answer is ‘yes’ to any o the above, please provide details :

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D D M M Y Y Y Y D D M M Y Y Y Y  

 Application No. : 

7/27/2019 Easy-Travel-Insurance-Proposal-Form.pdf

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10th Fl, Building N. 10, Twe B, DLF City Phase II, DLF Cybe City, Gugan-122002

Easy Tavel InsuancePpsal Fm

E-mail : custmesevice@apllmunichinsuance.cm ToLL FrEE : 1800-102-0333 www.apllmunichinsuance.cm

      A      M      H      I      /      P      r      /      H      /      0      0      1

      3      /      0      0      0      7      /      1      0      2      0      1      0      /      P

Please provide name and contact details o Your treating or amily doctor :

PAYMENT DETAILS

Instrument typeCash/Cheque/Debit/Credit Card/ Others

Instrument No. Bank Details Date Amount (in Rs)

Please make a crossed cheque/DD/Pay Order in favour of ’Apollo Munich Health Insurance Company Limited’only. Section 41 o Insurance Act 1938 (Prohibition o Rebates):

1) No person shall allow or oer to allow either directly or indirectly as an inducement to any person to take out or continue an insurance in respect o any kindo risk relating to lives or property in India any rebate o the whole or part o the commission payable or any rebate o premium shown on the policy nor shall anyperson 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 o theinsurers. 2) Any person making deault in complying with the provisions o this section shall be punishable with ne which may extend to ve hundred rupees.

 ADDITIONAL INFORMATION

[I there is insucient space to provide additional relevant inormation, whether as requested or otherwise, please attach a separate sheet to this proposal and return it to us.]

GENERAL EXCLUSIONS Following is an outline o the exclusions under the policy. Specic additional exclusions apply to various benets under the policy. For more details on the exclusions &waiting periods please reer the policy wordings beore purchasing this policy.We will not make any payment or any claim in respect o any Insured Person directly or indirectly or, caused by, arising rom or in any way attributable to any o theollowing unless expressly stated to the contrary in this Policy: War, war like operations; nuclear weapons/materials radiation o any kind; committing or attempting tocommit a criminal or unlawul act; participation or involvement in naval, military or air orce operation or any hazardous ; abuse or the consequences o the abuse ointoxicants or hallucinogenic substances such as drugs and alcohol; treatment o nicotine addiction or any other substance abuse; intentional sel injury or attemptedsuicide; obesity/morbid obesity and any weight control program; “AIDS” (Acquired Immune Deciency Syndrome) and/or inection with HIV (Human immunodeciencyvirus), venereal disease, sexually transmitted disease; pregnancy (including voluntary termination), miscarriage (except as a result o an Accident or Illness) exceptin the case o ectopic pregnancy; non allopathic treatment; charges related to a Hospital stay not expressively mentioned as being covered; Personal comort andconvenience items, vitamins and tonics; treatments rendered by a Medical Practitioner which is outside his discipline or the discipline or which he is licensed; out-station consultations and reerral-ees; treatments by a Medical Practitioner who shares the same residence as an Insured or a member o an Insured Person’s Family;the provision or tting o hearing aids, spectacles or contact lenses including optometric therapy; any treatment and associated expenses or alopecia, baldness, diabetictest strips, and similar products; any treatment that is not medically necessary; where purpose o travel is to obtain medical treatment; treatment o any pre-existingcondition, cancer, orthopedic, degenerative or oncology diseases unless to save lie in an unoreseen emergency or to relieve acute pain; cosmetic treatment; congenitalinternal or external disease.

This proposal will be the basis o any insurance policy that we may issue. You must disclose all acts relevant to all persons proposed to be insured that may aect ourdecision to issue a policy or its terms. Non-compliance may result in the avoidance o the policy. I there is insucient space or you to provide inormation, whether asrequested or otherwise, please attach a separate sheet. I you are in doubt, please seek the advice o your insurance advisor.

DECLARATION & WARRANTY ON BEHALF OF ALL THE PERSONS PROPOSED TO BE INSURED

I/ We hereby declare, on my behal and on behal o all persons proposed to be insured that the above statements, answers and/or particulars given by me aretrue and complete in all respects to the best o my knowledge and that I/We am/ are authorized to propose on behal o these other persons.

I understand that the inormation provided by me will orm the basis o insurance policy, is subject to the Board approved underwriting policy o the Insurancecompany and that the policy will come into orce only ater ull receipt o the premium chargeable.

I/ We urther declare that I/We will notiy in writing any change occurring in the occupation or general health o the lie to be insured/ proposer ater the proposalhas been submitted but beore communication o the risk acceptance by the company.

I/We declare and consent to the company seeking medical inormation rom any hospital who at anytime has attended on the lie to be insured/ proposer orrom any past or present employer concerning anything which aects the physical and mental health o the lie to be assured/proposer and seeking inormationrom any insurance company to which an application or insurance on the lie to be assured/ proposer has been made or the purpose o underwriting theproposal and/or claim settlement. I/ We authorize the company to share inormation pertaining to my proposal including the medical records or the solepurpose o proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.

Signature o the Proposer: Signature o the Advisor:

Date: Place:

Insurance is the subject matter of solicitation

FOR OFFICE USE ONLY    Apollo Munich Health Oce Code : Advisors Code & Name :

Branch Receipt Date : Channel Type :

Business Type : Urban/ Rural/ Social 

ET/PF/V0.01/072013