{"id":2649,"title":"‘A’ Proposal Form","purpose":"proposal","insurer":{"slug":"care-health-insurance","name":"Care Health Insurance Ltd"},"source_pdf":"https://cms.careinsurance.com/cms/public/uploads/download_center/en-ultimate-care----proposal-form.pdf","sha256":"f44bcaefb62f5d1c388800627a6ea593e89d3d407c166c4fcadc36cef8d14818","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities (proposers) to apply for the En Ultimate Care health insurance policy with Care Health Insurance Limited. The proposer fills the form with personal, nominee, insured persons, medical, and optional cover details.","notes":["The registered mobile number will be enrolled for WhatsApp notifications related to your Care Health Insurance Policy","The total percentage of contribution across all the nominees must not exceed 100%","In case you want to provide more than 3 nominees, please either provide a separate application or add the nominee via our website through Endorsement","Please share the medical documents wherever applicable","Use correct formats for dates (DD/MM/YYYY)","Attach original or valid documents for identity and address proof","Answer all medical and lifestyle related questions truthfully"],"title":"‘A’ Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Authentication Documents","fields":[{"help":"Tick all applicable identity proofs","type":"checkbox","label":"Proof of Identity (POI)  (      Tick whichever is applicable)","options":["PAN","Aadhaar","Passport","Driving License","Voter ID Card","Letter from a recognized public authority or public servant verifying the identity and residence of the Proposer"],"required":null,"pdf_field":""},{"help":"Tick all applicable address proofs","type":"checkbox","label":"Proof of Address (POA) (      Tick whichever is applicable)","options":["Electricity bill (not older than 3 months)","Aadhaar","Passport","Ration Card","Driving License","Telephone Bill (not older than 3 months)","Bank Account Statement (not older than 3 months)","Letter from a recognized public authority or public servant verifying the identity and residence of the Proposer"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Locality :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Village :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Gram Panchayat :","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark :","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Permanent Address : If same as above, please tick here","options":["tick if same"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Locality :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Village :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Gram Panchayat :","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Telephone :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number will be enrolled for WhatsApp notifications","type":"phone","label":"Mobile* :","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Alternate No. :","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email :","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth / Incorporation (in case Proposer is an entity) :","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender :","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status :","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Mother’s Name :","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality  :","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Form 60 (only in case the customer does not have PAN no.)   :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Last 4 digits only","type":"text","label":"Aadhaar Number (last 4 digits):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"CKYC:","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"By signing the Proposal form I give my consent for using my Aadhaar No. for Authentication of my Aadhaar Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Total across nominees must not exceed 100%","type":"number","label":"Specify the percentage (%) of the claim amount payable to each nominee in the event of the policyholder’s death","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Correspondence Address (If same as Proposer please tick here)","options":["tick if same"],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Permanent Address (If same as Proposer please tick here)","options":["tick if same"],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC or MICR code","type":"text","label":"IFSC/ MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Account Holder","options":[],"required":false,"pdf_field":""},{"help":"Provide Appointee Name, Relationship with Minor, Age, Mobile No., Email ID","type":"table","label":"Appointee Details (Only where the Nominee age is less than 18 years)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Proposed to be Insured Including Proposer","fields":[{"help":"","type":"text","label":"Name (Mr./Ms./Mrs.)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Provide if available","type":"text","label":"Aadhaar/PAN No. (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Name of nominee for this insured","type":"text","label":"Nominee","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City of Residence","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have ABHA No.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please provide ABHA Number (Optional)","options":[],"required":false,"pdf_field":""},{"help":"If Yes, enclose Disability certificate mentioning percentage of disability","type":"yes-no","label":"Do you fall under the category of Differently Abled Persons?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Percentage of disability","type":"number","label":"Specify the percentage of impairment","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Please enter the Unique Disability ID (UDID) Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical / Lifestyle Related Information","fields":[{"help":"Attach relevant medical documents if applicable","type":"attachment","label":"Please share the medical documents, wherever applicable such as discharge summary/ investigation reports/ follow up records/ angiography report/ latest ECHO, ECG, stress test.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Account Holder","options":[],"required":true,"pdf_field":""},{"help":"Tick whichever is applicable","type":"choice","label":"UPI-Mandate Confirmation","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"I hereby give my consent and authorize Care Health Insurance Limited to block the payable premium amount and debit the same from my Bank Account under Bima-ASBA facility on acceptance of my Proposal.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Benefits Selection","fields":[{"help":"","type":"yes-no","label":"Optional Benefit: Spouse Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Smart Select","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, select room type: General Ward max. up to Rs. 3000 per day / General ward / Twin Sharing Room / Single Private Room","type":"yes-no","label":"Optional Benefit: Room Rent Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention modified number of months","type":"yes-no","label":"Optional Benefit: Named Ailment Wait Period Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, select pre hospitalization days and post hospitalization days from options","type":"yes-no","label":"Optional Benefit: Pre-Post Hospitalization Expenses Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Premium Payback","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Unlimited Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Cover Pause","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Grace Period cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Tenure Multiplier","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Claim Shield","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Inflation shield","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention coverage amount","type":"yes-no","label":"Optional Benefit: OPD Reward","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention deductible amount opted","type":"yes-no","label":"Optional Benefit: Deductible","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention Co-pay percentage","type":"yes-no","label":"Optional Benefit: Co-Payment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention coverage amount","type":"yes-no","label":"Optional Benefit: Plus Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention coverage amount","type":"yes-no","label":"Optional Benefit: Women Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention coverage amount","type":"yes-no","label":"Optional Benefit: Mental Health wellbeing","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention coverage amount","type":"yes-no","label":"Optional Benefit: Durable Medical Equipment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention amount opted","type":"yes-no","label":"Optional Benefit: Out-patient Dental and Vision Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention amount opted","type":"yes-no","label":"Optional Benefit: Physical Consultations with General Physicians","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention amount opted","type":"yes-no","label":"Optional Benefit: Physical Consultations with Specialist Doctors","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention amount opted","type":"yes-no","label":"Optional Benefit: OPD Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Premium Freeze","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Chronic Disease Management Program","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"En Ultimate Care health insurance policy proposal","attachments":["Proof of Identity documents as ticked","Proof of Address documents as ticked","Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test if applicable","Disability certificate mentioning percentage of disability if proposer or insured is differently abled"],"declarations":["By signing the Proposal form I give my consent for using my Aadhaar No. for Authentication of my Aadhaar Details","I hereby give my consent and authorize Care Health Insurance Limited to block the payable premium amount and debit the same from my Bank Account under Bima-ASBA facility on acceptance of my Proposal"],"dropped_labels":9},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/care-health-insurance/2649-a-proposal-form"}