UNITED INDIA INSURANCE CO.

LTD
Do12: Bancassurance Divisional Office, IML Building , N.R.Square, Bangalore-560002
PROPOSAL FORM FOR V-HEALTH CARE POLICY CUM PERSONAL ACCIDENT for VIJAYA BANK ACCOUNT HOLDERS
Contact Details: United India -080-22113100/22113101/02,Vijaya Bank 080-25584066Ext-328/475/383
1. NAME & ADDRESS OF THE ACCOUNT HOLDER ( In CAPITAL LETTERS) ( To be filled by the Bank)
a. Branch Name:
b. Branch Code :
c. City :
. d. Account No:
.
CITY PIN e. Finacle Tran Id
f. Vijaya Bank Staff : Yes /No
Email Id ... Mobile. If Yes: Staff Code No:
2. SUM INSURED PER FAMILY ( Please ) Premium :
Rs.50000/ Rs.1Lac/ Rs.2Lac/ Rs.3Lac/ Rs.4Lac/ Rs.5Lac
3.DETAILS OF PERSONS TO BE COVERED :
Sl.No NAME OF THE INSURED DATE OF AGE SEX RELATIONSHIP EXISTING
. PERSONS BIRTH DISEASE/
[DD-MM-YY] ILLNESS/INJURY
1
2
3
4
Additional sheets may be used wherever required
4.Period of Insurance : One Year from the date of Policy

I hereby declare and agree that the above mentioned details are true and complete. I and family members are maintaining good health subject
to existing diseases/illness/injury as per Serial No.3 above. I have read the salient features of the policy and willing to accept the cover subject to
the terms, conditions and expectations as prescribed by the Insurance Company. Enclose copy of existing medical insurance of cardholder or
other family members. I/We agree that Vijaya Bank is no way responsible for claims under V Health Care or renewal of the Policy/ receiving of
renewal notice/ renewal premium and same has to be persued with the T.P.A/ Insurance Company

PLACE:
DATE : . SIGNATURE OF THE PROPOSER

This is to Certify that Sri/Smt. .. [Name of the account holder] is maintaining an account with the bank, bearing a/c
no ..

SEAL OF THE BRANCH SIGNATURE OF THE BRANCH MANAGER

Premium No. of Persons ( Service tax 15% ) Chart:

Sum Self Self + Spouse Self + Spouse Self + Spouse +

Insured +Child Two Children
1 1+1 1+2 1+3
Rs. Rs. Rs. Rs.
Rs. 50,000 964 976 987 999
Rs.1,00,000 1866 1889 1912 1935
Rs.2,00,000 3518 3566 3612 3657
Rs.3,00,000 4913 4984 5052 5122
Rs.4,00,000 6137 6228 6319 6413
Rs.5,00,000 7360 7477 7590 7706