— (443) _ INSURED + SPOUSE + TWO DEPENDENT CHILDRENS, lakh 35 Lakh 4 Lakh 45t0Kn SLakn $$ Se ee ee ee ee ee ee ee | ‘SUM © Taxes Payable Extra (GST/ SGST/1GS7) ‘© Syndicate Bank sa Licenced Corporate Agent of United India Insurance Company Limited stomers in insurance product is purely on volanary basis. ‘BENGALURU BANCASSURANCE HUB :IFCI BHAVAN, 3rd FLOOR, No, 2, CUBBONPET MAIN ROAD, NAR. SQUARE, BENGALURU560 002. Phone :080:32113100 / 22113101 UNITED INDIA INSURANCE CO.LTD. BENGALURU BANCASSURANCE HUB IFC BHAVAN, 3rd FLOOR, No, 2, CUBBONPET MAIN ROAD, NR. SQUARE, BENGALURU-560 002. Phone : 080-22113400 / 22113401Taeacia #; SyndicateBank ‘SYNBK CODE BIC CODE 9}|2{a]o]olo LJ UNITED INDIA INSURANCE CO. LTD. ‘At United India , It’s always U before | SYNDARAOGYA PROPOSAL FORM Group Mediclaim Insurance Cum Personal Accident for Syndicate Bank Account Holders 1. NAME & ADDRESS OF THE ACCOUNT HOLDER (Tobe filed by the Bank) (Gn CAPITAL letters) 3. a Branch Name/City . BIC Code 2,__ SUM INSURED PER FAMILY (Please tick () ‘. Proposal frm (Please tick) Re. 0.5Diecs [ Re L00%ecs [ Rs 1s0lacs | Re200Ie | Re 2S ls feral/Seri Urbon/Uibae 4, Account No. Rs. 30Diacs | Re3.50iacs | Rs 4.00lacs | REASOIec | Re 500s ee cry '8B/CA/FD/others (PL. specif) 5. DETAILS OF PERSONS TO BE COVERED - (Pease tick ): Under Plan A(_) Under Plan B( ) st [NAME OF THE INSURED PERSON Date of [BISTING DISEASE / No. (in CAPTAL LETTERS) eS) IMLNESS / INJURY 1 eae ssasagaas i v v ana as eel ano 6. swAMPS POTOGRAPOF THE MSURED PERSONS AOCOUNTHOLDER SPOUSE cr cm? Pana Pane? PREMIUM CHART SUM INSURED 50000 | 100000 | 150000 | 200000 | 250000 | 300000 | 350000 | 400000 | 450000 | 500000 PLAN A (+3) INSURED, SPOUSE, TWO DEPENDENT CHILDREN) PREMIUM 1234 | 2385 | 3496 | 4501 | saai] 6292 | 7077 | 765 | esa | saat PLAN B (15) INSURED, SPOUSE, TWO DEPENDENT CHILDREN) AND PARENTS. PREMIUM 2060 | 3982 | 5932] 7,504 | 801 | 10.479 | 11,784 | 13,090 | 14,307 | 15,703 + GST Extra NAME OF THET.PA.: VIDAL HERLTHTPA PVT.LTD, _] M/s. MEDIASSIST HEALTH SERVICES PVT.LTD. { ] GOOD HEALTH INSURANCETPALTD,,[ | HEALTHINDIATPA SERVICES [ } 8. thereby declare and agree thatthe above statements are true and complet. Mysel andy fly members are maintaining good health except the existing diseas/iines nuns per Serial No. Sebo. Ihavereaathe sates te polo an willngto aces the cove Subject te ems condtions ‘and exceptions prescribed by the Insurance Company. Enclose copy of exsting medical insurance of account holder or other famiy members. 1 We agre tat th Syccate Banks no way response orcas unde Syeda ad same have tbe pursued ‘th be parular TPA. nutance Compan. SIGNATURE OF THE PROPOSER PUCE