{"id":2650,"title":"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/protect-plus---proposal-form.pdf","sha256":"738478a24813a38816a6949b2e3387b02a0540651717922dd8fb4d42ed72e4e0","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer to apply for the Protect Plus health insurance policy with Care Health Insurance Limited. The proposer fills it to provide personal, nominee, policy, and payment details.","notes":["Fill in CAPITAL LETTERS only","Use Additional Information section if insufficient space","Registered mobile number will be used for WhatsApp notifications","Attach copy of cancelled cheque with proposal form","If paying by cash, do so only at nearest Care Health Insurance branch or authorized bank branch and obtain computerized receipt","Any claim without computerized receipt against cash payment will not be admitted","If applying for portability, fill separate Portability Form","Total nominee percentage must not exceed 100%","If nominee is minor, provide appointee details","Agent must explain contents of proposal form to proposer","Proposal receipt is not acceptance of risk or commencement of policy","Policy issuance subject to underwriting decision and receipt of premium and medical reports"],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name in capital letters","type":"text","label":"Name : (Mr./Ms./Mrs.)","options":[],"required":true,"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":"text","label":"Name of Base Product:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Base Policy Number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address :","options":[],"required":true,"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":"","type":"number","label":"Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Landmark :","options":[],"required":false,"pdf_field":""},{"help":"Tick if same as Correspondence Address","type":"text","label":"Permanent Address :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Telephone :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile will be used 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":"","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":"","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality  :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","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":"number","label":"Aadhaar Number  (last 4 digits):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"CKYC","options":[],"required":false,"pdf_field":""},{"help":"Select at least one","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":true,"pdf_field":""},{"help":"Select at least one","type":"checkbox","label":"Proof of Address (POA)","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":true,"pdf_field":""},{"help":"","type":"choice","label":"Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If you have an eIA, please provide following details: I) Name of Insurance Repository :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"ii) eIA No :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"iii) Name as appearing in eIA :","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account (eIA) Options","fields":[{"help":"","type":"choice","label":"If you do not have an eIA, would you like to open an account?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Yes, choose any one Insurance Repository:","options":["NDML – NSDL Data Management Limited","CAMSRep- CAMS Insurance Repository & Services","KARVY Insurance Repository Limited","CIRL-Central Insurance Repository Limited"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Help us preserve the environment by opting to receive policy related information in soft copy/via email only :","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"For up to 3 nominees","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"Total 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":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Permanent Address (If same as Proposer please tick here)","options":[],"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":"","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":"Columns: 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":"Policy Details","fields":[{"help":"As per Base Policy","type":"text","label":"Tenure :","options":[],"required":false,"pdf_field":""},{"help":"As per Base Policy","type":"text","label":"Cover Type :","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Section 1- Global Plus: (If Yes, Please Specify the Optional Benefits below, if opted )","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Geographical Coverage:","options":["Worldwide excluding India","WW excluding USA, Canada, India"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Plan Name:","options":["Basic","Premium","Elite"],"required":false,"pdf_field":""},{"help":"As per Base Policy","type":"text","label":"Sum Insured:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Benefit 1: Maternity Expenses","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"For Maternity Expenses if opted","type":"text","label":"Sum Insured:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Benefit 2: OPD cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"For OPD cover if opted","type":"text","label":"Sum Insured:","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Optional Benefit 3: Modification of Waiting Period","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Benefit 4: International Second Opinion","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Benefit 5: Modification of Advance Technology Methods","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"(If Yes, then please select - 50% / 100% of SI )","options":["50%","100%"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Section 2- Plus:","options":["Yes","No"],"required":false},{"help":"","type":"choice","label":"Base Benefit 1: Unlimited E-Consultations","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, select 60/180 days, 90/180 days or No limit","type":"choice","label":"Base Benefit 2: Pre-Post Hospitalization Expenses Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, fill separate Portability Form","type":"choice","label":"Are you applying for portability?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"Strike out whichever is not applicable","type":"choice","label":"Payment By:","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)","Reward points","Wallet","Any other mode"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Cheque / Demand Draft No. / Authorization ID :","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Payment Amount (`) :","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount (`) :","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Account Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code :","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Tick whichever is applicable","type":"choice","label":"UPI-Mandate Confirmation:","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Authorizations","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date  :","options":[],"required":true,"pdf_field":""},{"help":"Sign on behalf of all persons to be insured","type":"signature","label":"Signature of the Proposer/ Authorized Representative*  :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place :","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration Questions","fields":[{"help":"If Yes, provide details on separate sheet","type":"yes-no","label":"Have any of the person(s) to be insured ever filed a claim with their current/previous insurer?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any of your proposal(s) for Health insurance been declined, cancelled, charged a higher premium or issued with special condition(s)?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any of the person(s) proposed for insurance covered under any other health insurance policy with the Company or any other Company without break?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Previous or Existing Health Insurance","fields":[{"help":"For each insured person","type":"date","label":"Since_____","options":[],"required":false,"pdf_field":""},{"help":"Columns: Insured 1 to Insured 6 with Yes/No and dates","type":"table","label":"Particulars","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Declaration","fields":[{"help":"Agent/Advisor name","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"License No. (Advisor/Corporate Agent/Broker/Relationship Officer):","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature :","options":[],"required":true,"pdf_field":""},{"help":"Sales person name","type":"text","label":"SP Name :","options":[],"required":false,"pdf_field":""},{"help":"Sales person code","type":"text","label":"SP Code :","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Addendum – Vernacular Declaration","fields":[{"help":"Person who explained the form in vernacular language","type":"text","label":"Name of the Declarant","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Declarant","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"declarant"}],"deadlines":[],"applies_to":"Protect Plus health insurance policy proposal","attachments":["Copy of cancelled cheque","Details on separate sheet if claim history or proposal history questions answered Yes"],"declarations":["Information given is true and complete to the best of knowledge","Information forms basis of insurance policy and policy comes into force only after full premium payment","Notify in writing any change in occupation or health after proposal submission but before acceptance","Consent to company seeking medical and insurance information for underwriting and claim settlement","Consent to share proposal and medical data with government and regulatory authorities including ABHA"],"dropped_labels":2},"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/2650-proposal-form"}