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Star Health and Allied Insurance Company Limited

No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in

Version 2
Format for Business Acceptance / Quote - GMC
I Insured / Proposer Details
1 Name of the Insured / Proposer
2 Address of the Insured / Proposer
3 Location of the persons to be covered
4 Business of the Insured / Proposer
5 Name of the contact person of the Insured / Proposer
6 Contact number of the Insured / Proposer
7 E-mail id of the Insured / Proposer
8 Website Address of the Insured / Proposer

Whether Employer - Employee group or Non employer-


II 1 Employer-Employee Group
employee group ( Pl.tick the appropriate one )

If Non Employer-Employee Group , please specify the


Members / Account Holders/ Loanees/ Students/ Depositors / Others
2 nature of relationship between the insured / proposer and
( Pl.specify )
the insured persons

III Intermediary Details


Name of the Intermediary (Agent / Broker / Others-
1
Pl.specify)
Code Number of the Intermediary (Agent / Broker / Others
2
- Pl.specify)
3 Phone number(s) of the intermediary
4 Email id of the intermediary
5 Name of the Sales Manager, if applicable
6 Code Number of the Sales Manager
7 Phone number(s) of the Sales Manager
8 Email id of the Sales Manager

Whether Renewal or Fresh, please metion/ tick the


IV
appropriate one

If Renewal , Pl.answer the following .


V TPA Details (under the expiring policy)
1 Name of the TPA
2 Address of the TPA
3 Contact details of the TPA
4 Landline no.
5 Mobile no.

VI Expiring Policy Details


1 Name of the Existing Insurer
2 Policy No.
3 Policy Period From : To :
4 Scope of cover

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Star Health and Allied Insurance Company Limited
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in

Version 2
Format for Business Acceptance / Quote - GMC
4.1 Policy Type FLOATER
4.2 Waiver of waiting period of 30 days YES
4.3 Waiver of first year exclusions Y
4.4 Waiver of First two year exclusions Y
4.5 Cover for PED Y
4.6 Cover for Maternity NO
Limit of coverage for Maternity For Normal : For Ceasarian :

4.7 Maternity waiting period NO

4.8 Cover for new born child from day one


If new born child is covered from day one, please specify
4.9 On full floater sum insured basis / any other limit (Please specify)
the limit of coverage for the child
4.10 Whther Corporate Buffer was offered Yes / No

Restricted to critical illeness only or for all illnesess


4.11 If corporate buffer was offered, please speify the terms
Limit for usage of corporate buffer : floater sum insured / others (pl. specify)

4.12 Any other coverages offered under expiring policy Please mention.
Policy copy with terms / conditions including extensions is to be mandatorily provided by the proposer
Premium under expiring policy as at the inception
5 Rs.
(excluding service tax)
Refund premium on account of deletions during the year
6 Rs.
(excluding Service Tax)
Additional premium on account of additons during the year
7 Rs.
(excluding Service Tax)
Final Premium under expiring policy (as on the date,
8 Rs.
please specify) (excluding service tax)

VII Details of persons covered under the expiring policy


Basis of premium charging Per family / Per member basis
Employees Dependants Total
1 Number at the inception
2 Additions during the policy period
3 Deletions during the policy period
4 Number of persons as at expiry

VIII Details of persons to be covered now for renewal


1 No.of employees
2 No. of Dependent Spouse
3 No. of Dependent Children
4 No. of Dependent Parents
5 No. of Dependent Parents-in-laws
6 Other Dependents(Siblings etc.,)
7 Total Number of Persons to be covered
Age wise Distribution of Employees only
8
(in completed years)
0-35
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Star Health and Allied Insurance Company Limited
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in

Version 2
Format for Business Acceptance / Quote - GMC
36-45
46-55
56-65
66-70
71-75
76-80
Total
Sum Insured Per Person/ Per Family (Rs.)
If different sum insured is opted for different catogories of
9
the employees, please provide the details in the sheet 2
attached

IX Claims details under the expiring policy as on ____________________ (please specify the date)

Reimbursement Cashless Total


A As inpatient
No. Amount in Rs. No. Amount in Rs. No. Amount in Rs.
1 Claims Paid as on the above date
2 Claims outstanding as on the above date
B Under OPD if any.,
1 Claims Paid as on the above date
2 Claims outstanding as on the above date
C Under Corporate Buffer if any.,
1 Claims Paid as on the above date
2 Claims outstanding as on the above date
Total (A+B+C)
Total Claims Paid during the last two policy years
D
immediately preceeding the expiring year
Total claims paid during the last three months of two years
E
of the policy immediately preceeding the expiring year

X Details of cover required now for renewal


1 Family Floater / INDIVIDUAL
2 Waiver of 30 days Waiting Period
3 Waiver of First Year Exclusions
4 Waiver of First Two Years Exclusions
5 Cover for Pre Existing Diseases
6 Maternity Extension
If Maternity Extensions is required, Limit for Maternity
7 NORMAL : CESARIAN :
Expenses
Whether Waiver of 9 Months waiting period for Maternity
8 is desired (otherwise maternity cover will be subject to 9
months waiting period)
Cover for Pre and Post Natal expenses (within maternity
9
limits)
Limit for pre and post natal expenses
10 (a) Child Cover from day one is desired

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Star Health and Allied Insurance Company Limited
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in

Version 2
Format for Business Acceptance / Quote - GMC
10 (b) If yes, Please specify
11 (a) Corporate Buffer Aomunt if any
11 (b) Maximum sum insured under Corporate Buffer per family
Maximum number of cases during the policy period for
11 ( c)
Corporate Buffer if same is to be capped
12 (a) Room Rent Limits - for Normal / ICU
12 (b) Room Rent Limits - for ICU
13 Pre Hospitalisation
14 Post Hospitalisation
15 Copay
16 Any other requirement of cover. (Pl. specify)

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

Date :
Place :

Signature of the Designated Official of the Insured/ Intermediary

With Name and Designation

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