Proposal Form No. STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034, * Phone ; 044 - 28288800 * Email : support@starhealth.in Website : ww.starhealth in % CIN : U66010TN2005PLCO56649 + IRDAI Regn. No. : 129 COMMON PROPOSAL FORM [eae ‘Tha campany wi oe on Fk unl he proposal has bao ace ans ul payeont of premium nas been reseed Unique Reference No: SHAVPROOO? FENII pee eperiartlteng Paley Isung Ofes su suing sw cove Ra AGENT AGENT CODE NAME SPECIFIED} SPECIFIED PERSON PERSON ODE NAME FA 5a Seer Consator BYR SW Wa” Ba. vera So Sb Ohare of Pano k Ge ctom Vunaes etree Se ms Setar Puls eo tsar ts tn nc py ht a sn a i nt gas an en - roc on pte pr rh iy Classica (Ts dassticton is bared upn he adres ole propose) Urban Rural Tans fis rope ts Propose Tat of Seep ti sea aes foals ne Phtom ceases Pin oie emi ah ar Faisdothere | Fon . GST Mater Pa aber EI vonin's name El Relationship to ED “hetronse Dates Te rane te oper Taoaip (if nominee is a minor) the Nominee Age (Incase of Multiple nominees a separate form containing nominee detalls should be enclosed duly specifying thet to each nominee ) ESOPRSIY account Number Tp of Account; VSB CICA Ca Otel specty bry Peg Sore ote Bank Nare ofthe Branch FSC Code Pease attach a photo copy of canceled cheque eal of the above Bank Account. ‘Arnval roman Rs Wa of Payant:Cath/ Chava Cra Cre Dati Care) NEFT CC Manda ‘Cheque /DD No Date Drawn on Branch ‘Common Proposal Form toaver ‘Star Health and Aled Insurance Co. Ld Insured person Deals (Pease il inthe respective column fr each person proposed tobe covered) Common Proposal Form ER Insured Persor ieee ees iio eee Name Gender Date of Binh Height ems) Weights) ons Kos ous Kos ous Kos ous xes| ous «65 Relationship with proposer Occupation “Annual Income (Rs) Do you want Goi Plan (Applicable for Medelassie Insurance Pole (nd) Mss) ce) ue Missi) Sum insured Opted (Rs) "Rigor [opis fr Media sone Foley waa Soyounataggenceven AYES PAR HA'O! Hospisicesh | Pajencow | Hosptalcasn | Patentcae Patenscare | Hospital cash | Patertcare | Hosp Cesh | Patient care ‘Rovere tape) 1. Name of the 2. Period of insurance 5, Sum insure (Rs) 1 PoteyN, 4. Almentfor wich Clim was made | Year 2. Claim Amount Pai / Rejected Family Physician's Namo Phone Regn No "the person proposed for insuracen ged heals and tea i and mt dene oy a he paren proposed ensure conse! slogan ate teat ies ese 3 Doss ie parson propeed fo ineurancs have tomplcslons ann flowing oe eee Dib Melts 1Ye, sce when 1) HBR Clete Yes, soe when Hear Diese Yen se when ae ig aac, cone Pa Taber, tia cer epratayiretans-1 eaves wen ” Bia tes Ft pe a a ar, a) Cane 7 re Caner Lein- IY ens whan herons area terectony You, nee whenree 1) Treatment for ub erty or hat been avid fr? (arama If Yu provi dtl, Tava of son, re, Let Ga 7 Dusaee- ee ser when iu 1) Deseo Prostrate Fira /Ples Gent di tte see whe 1) Aay Other rola Pease Spc AV unergonu ay ase et? By Prescribed any meinen yes 1) Name te es fr wie ele presented hve ben 1, Dota of mas ne raps rss. ©. Been asd or any surgery weamen 7-165, ge 7 eran iy Inn inea! ene. Se dts 3) Shen Tdaceo- esac when yoke snc when ©) Consume Alcoa Yes sae when 2 apse a aca pons TAF sn ur teu Pane seach oh apical fr Stax Comprehensive insurance Ply 8 Ba bah PED Open ovr eure? YESNO YESNO YESNo YESNO YESNO 4 Dost rsd cpio eur rg rai So mind e838, {Moen som ner po ssa aac exh eran eb ny cbt ‘Sulit sm nd op banc Fer eon ore Myron spec Men be sum Me. ee ee eT LE ee eee LE ee eee Ee Te eee Pee OT eared ete Code Soe Por‘STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED TAR ‘Acknowledgement Recsved he proposal fo. oy fom MM Ms, slong wen payment Rs -by Cash vide Chaqu 0 No at au. The CathiCheqe gen by yous baad fer opeatenal conenenoe an barking othe Cesnidhequ des natmein acestanoe of ry us. Th eco aha Cash’Chaqe wil do be aknanlogedby aur ode de advance parm recat io proposal accptd, he cower wlconeanos Harte dats fhe evancepanium ecb, sujet torealuaton of the Cogue Ibe proposal srl acopad te aout pai ibe che. Con in caso ply is nol recived witin 15 days rom the dato of payor of romium, Signature of the Date Place Name & Code ofthe authorised person authorised person ey rary FAMILY HEALTH OPTIMA INSURANCE PLAN ‘MEDICLASSIC INSURANCE POLICY (NDIVIDUAL} ‘SENIOR CITIZENS RED CARPET HEALTH INSURANCE POLICY Or UID No. IRDAUMLT/SHAUP-Hv129/2017- UID No. SHAHLIP20063V031920 UID No. SHAHLIPtS101V031819 og ysodorg uowniog (402/3n/NonmeD 04d rer UID No.: SHAHLIP2077v041920 UID No. IROAIN-HLTISHAUP-H(C\V.IT38/3-14 UID No. SHAHLIPtB088v021718 UID No. IROANLHLTISHAUP-HNAI393-14 ‘Sum Insured Options AvailableRs.inLakhs*(v): 1 Q18 G2 Q3 QO4 05 Q75 Of O% OQ OS Qs O75 O 100 Family Size (AAdult, C=Child) (7) 2 Ota OtAMC | QtAC OO TANC oa zac O 2ae2c 2as3c * please check brochure forthe available sum insured option in respect of each product, STAR COMPREHENSIVE INSURANCE POLICY ] STAR CRITICARE PLUS INSURANCE POLICY ] STAR HEALTH GAIN INSURANCE POLICY ] ‘TAR FAMILY DELITE NSURANGE POLICY Pease a protograph of Pease aff hotagapho Pease fix shtoraph of Pease fix photograph of Pease af protograph o sured Person Innes Person? Tested Peeon 2 reed Parson = Inses Person 5 Name Nan: Name None Nan Dacron + hry eon my beat don etal ofa rons peporen beste sto etna anes ander pares ghey aren and cron al space eto my role ant am adres pos rst of has bps 2. lunes ‘tbetnomaien pondedby ne rn Ps aie nsesnoe pale supe Bae ppc urate le sue ad ale oly wl camo > ace ey at pana ae penn aah {er cecar at aint ng ey charge czar ness eal el. ea be esuscyopese ater pops has been etme bbe cormcaan bk scans ye cosy dear and conse conpary ekg mad lnfrsen evar ocr ram hosp wich atari a alee one pron be td ram any lr realy cca any wie tc yal atl ath fe parc abe ned pepo a dng iota ary eu a 5 lauteaeihe saan br oat etic omy oon eig he mda zn al he auecrapon fo hs pupa srg ops ar err aera ar th ary Gera acu abo ear a arte ace oh my car ark een acon a be soz fs orm osu oneal hua conf tat he ature of he roduc have bon unastaed bye | uncereansathe eamiceque gels Bred fr pein cnsronce and cmmencamont f ki supe aca of proposal you. lnprsion ot 'WHERE THE PROPOSER I ILLITERATE OR SIGNS INA LANGUAGE DIFFERENT FROM THAT OF THE: te repon PetaStar Theby confi thatthe deals have boon explains tothe propos, [Name of the person who explained Signature ofthe person who explained ‘Signature | Thumb impression ofthe propos ‘oN wo Jesodorg