Name [ ) ia) Address; Oo cy (QUILL Phone [J I IL If essence woe QOOOOOS00G era QOO0000S5b0000R PANNo.[ J (\( (J JL) JU) Occupation: CiBusiness C)Service C1 Not Employed [] Student Policy Opted C] Individual C] Group C] Family Medicare C) Top-Up C1 Super Top-Up (Peace repel akin oman an eee ey) Total Number of Persons to be covered{ || ]{_ |. (Peso op das prt stad ace) Service TaxRegn.No.f [I | If JC) Sl No. Relationship Name Age} Gender | sith Proposer Occupation | Sum Insured* 6 7 “T Fomiy Medicare, Roster sum sured tobe ndeaed Policy Commencement Date [1 (0 ][ 11), Has any proposal for this insurance or | C]Yes CINo any other health insurance been refused or cancelled or higher premium charged, If so, give details. Place [ For Official Use only oe Name Date { TPA Code Intermediary Code Signature of Proposer .Copgee Y Pees OE PLEASE FILL WITH BLOCK LETTERS * If more than one person is to be covered, please take additional copies ofthis form and complete the same for each insured person Name Address Affix passport size photograph City jao0o0o00o ( ( here Pncode( JJ) oa JOMMV OL J Height ()(_} () Weight (_]( } BMi[ }[} Blood Group [ incms Lo inkgs. JS J L (Ill) LIFESTYLE Smoking ‘Alcohol Food | SportsActivies | RegularExercise | Recreation 1 1 Packiday Habitual | Veg, Di Gricket Gym Ate youa 1 Less Than Social CNon-Veg, |Z Hockey CWalking | Member of a 1 Packiday oni Foot Ball Health Club [Others yes CNo (IV) INSURANCE HISTORY (last 5 years) Date of first policy Type of | Period ot] sum | Claim | Reason Name of the Insurance Co, Policy No. | Poticy. | insurance| Ineured| Amount | for Claim NCBICB Whether any insurance company has refusedicancelled a policy? ClYes [INo PRE-ACCEPTANCE TESTS APPLICABLE ABOVE 45 YEARS (Enclose Test Reports). Lipid Profile Specimen SignatureQ), bes OLN AYA ae DIABETES: Date of Diagnonis Did you suffer from coma or procoma ? Do you take any anti diabetic drugs ? Ifo, please give names with dosage. Please give details of Fasting and post prandial Blood Sugar readings. HYPERTENSION What is your Blood Pressure reading? Please state with dates. Please state name of antihypertensive drugs with dose. ‘Are you a smoker ? Dyes CINo Is it essentialisecondaryimalignant Hyertension Please stale whether you have suffered from any complications or other diseases. CARDIAC HISTORY. Did you ever suffer from chest pain or coronary insufficiency ‘or myocardial infarction ? If so, please give diagnosis and date. Please state name and dose of drugs you are taking at present Please state the findings with dates of investigations done like ECG, Stress Test, Coronary Angiography, X-ray, Pathology reports etc., Please send reports with the prescribed form. Have you suffered from or are suffering from any illness during past 48 months (Prior tothe inception of this policy CYes [No Ityes, give details TO BE COMPLETED BY CONSULTING PHYSICAN / SURGEON (Reports to be atchea) Name of the Patient Complaint / Investigation Treatment Past Treatment Recommended Medication | Any Other Surgery_[ Medication’ ‘Any Other | for Insurance Name Address( State Place { Date [ Signature ofthe Medical PractitionerPLATINUM / GOLD / SR. CITIZEN / FAMILY MEDICARE Floater Sum Insured (For Family Medicare only) (Abrief note giving details of the scheme will hel in better evaluation of your proposal) Add-on Covers Opted - Hospital Daily Cash (750 [1500 Ambulance Charges Des CINo ROROGy ars [aaa ‘Number of Persons jest Extensions Opted - Maternity Benefits ee Claims Experience Fee 2000 —[ 00% TOP-UP POLICIES You are opting for CTop-up Policy Cl Super Top-up Policy Do you wish to have Policy on Cindividual Basis Family Basis Parents can be taken under a separate policy. ifonIndvidval basis, indicate option foreach individual person [Opto Sum ured Speciieg Teoh vet sot q . soto oo Sous i = 18 chic. o z 0,00 cnia.2 a F 2 5.00000 ies 1.00.00 3.0.00 ‘Are any ofthe Insured person(s) at present or have been at any other time in the past covered under any Medical Expenses Reimbursement Scheme. Ces [No Please furnish the folowing (Strike-off wherever not applicable) ‘Scheme provided by: | [1 Employer C1 Others Name of the Employer Others Persons Covered ‘All those who are proposed for coverage under this policy (or) only some persons. Expenses Reimbursed ‘Any hospitalisation / only specified diseases ‘Amounts Names of the persons covered under the scheme Eligible Reimbursement Amount Remarks Claim amounts receivedireceivable in preceding five years including expiring policy / reimbursement scheme Name of the Insurer / Reimbursement Provider Policy No. / ‘Scheme Name Period of Hospitalisation Claimed Amount ‘Amount settled/pending for settlement TPA, if lines Applicable Signature of Proposer