| |
| |
 UNITED
INDIA INSURANCE Co. Ltd.
(
A Govt. of India Undertaking)
Branch Office:Post Office Junction, Changanacherry - 686 101, Phone : 0481-2422363
|
|
| |
ACCIDENT AND HEALTH
CARE POLICY
PROPOSAL FORM |
| |
|
Proposer
Name
and
Address
(Use capital
Letters
|
Sri/Smt |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Phone |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Pin |
|
|
|
|
|
|
|
|
| |
|
|
2. Insurance Cover Opted |
SINGLE COVER
( Tick Type) |
A |
|
B |
|
C |
|
D |
|
E |
|
Office Use |
Janatha Personal Accident |
50,000 |
1,00,000 |
50,000 |
1,00,000 |
1,00,000 |
|
|
50,000 |
1,00,000 |
50,000 |
1,00,000 |
1,00,000 |
|
Medi-Guard |
** |
** |
10,000 |
20,000 |
35,000 |
|
|
| |
FAMILY
(TICK) |
F |
|
PROPOSER |
SPOUSE |
1st CHILD |
2nd CHILD |
Office Use |
Road
Safety Insurance |
1,00,000 |
|
25,000 |
25,000 |
|
Medi-Guard |
10,000 |
10,000 |
10,000 |
10,000 |
|
|
| |
|
| |
3. Details
of the persons to be insured ( Self / Spouse / Son
/Daughter ) |
| |
Name
of the Insured Person |
Age |
Sex |
Monthly Income
(Rs.) |
Relationship
with Proposer |
1 |
|
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
|
| |
| |
Have
you suffered from iabetes/Hypertension
/Heart
ailments/ Any Disability or any other illness?
If yes, Give
details
|
Nominee |
Relationship
with Insured |
1 |
|
|
|
2 |
|
|
|
3 |
|
|
|
4 |
|
|
|
|
| |
|
|
I
hereby declare that the information furnished above
are ture and correct to the best of my knowledge
and belief. I also declare that the Terms / Conditions
/ Exclusions etc. governing the Policy have been
read and understood by me and I hereby agree to
be bound by the same. |
|
| |
|
|
| |
Place:
Date : |
Signature of Proposer |
|
| |
|
|
| |
Witness to Nomination :
1
Name & Signature:
Address : |
2. |
|
| |
|
|
| |
|
|
|
