{"id":2652,"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/care-advanced---proposal-form.pdf","sha256":"48b378c9af3978055f918ddc18918d8470670c195945e8270103d5fd523143c0","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the proposer (policyholder) to apply for a health insurance policy with Care Health Insurance Limited.","notes":["Fill the form in CAPITAL LETTERS only.","Use additional information section if space is insufficient.","Registered mobile number will be enrolled for WhatsApp notifications.","Total percentage of claim amount payable to nominees must not exceed 100%.","If paying premium by cash, do so only at authorized branches and obtain computerized receipt.","Attach copy of cancelled cheque for NEFT details.","This form is only a proposal; policy issuance is subject to underwriting and acceptance by the company.","If proposer cannot read/write or has disability, vernacular declaration must be completed by a declarant.","Original bills and documents may be required later for claims."],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Proposal No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"URN:","options":[],"required":null,"pdf_field":""},{"help":"For office use only","type":"text","label":"Intermediary Code :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Intermediary Name :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Intermediary RM Code :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Branch Code :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Customer Acc No.:","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"CHI RM Name :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Branch Code :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Client ID :","options":[],"required":false,"pdf_field":""},{"help":"For office use only","type":"text","label":"Receipt ID :","options":[],"required":false,"pdf_field":""},{"help":"Provide at least one of Aadhar Card No. or PAN Card No. and name","type":"text","label":"Details of ‘Point of Sales’ Person : (To be filled in if the Policy is sourced through ‘Point of Sales’ Person)","options":[],"required":false,"pdf_field":""},{"help":"Fill proposer full name in capital letters","type":"text","label":"Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":true,"pdf_field":""},{"help":"Fill full correspondence address","type":"text","label":"Correspondence Address : Locality, City, Village, Gram Panchayat, Pin Code, State, Landmark","options":[],"required":true,"pdf_field":""},{"help":"Fill permanent address or tick if same as correspondence","type":"text","label":"Permanent Address : If same as above, please tick here; else fill Locality, City, Village, Gram Panchayat, Pin Code, State","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Landline (Residence) :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Office :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number will be enrolled for WhatsApp notifications","type":"phone","label":"Mobile No . :","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":"Use 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 : Male, Female, Others","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status : Single, Married, Divorced, Widow(er), Separated","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"Provide PAN or Form 60 if no PAN","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Nationality : Indian, Other than Indian","options":["Indian","Other than Indian"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Form 60 (only in case the customer does not have PAN no.) : Yes, 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":"Tick all applicable proofs","type":"checkbox","label":"CKYC Please share the following for authentication purpose : 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":false,"pdf_field":""},{"help":"Tick all applicable 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":false,"pdf_field":""},{"help":"","type":"text","label":"Mother’s Name :","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Policy Issuance and Nominee Details","fields":[{"help":"","type":"choice","label":"Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? Yes, No","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":""},{"help":"","type":"choice","label":"If you do not have an eIA, would you like to open an account? Yes, No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Yes, choose any one Insurance Repository:","options":["CAMSRep – CAMS Insurance Repository & Services","NDML – NSDL Data Management Limited","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 : Yes, No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill if nominee is minor","type":"table","label":"Appointee Details (Only where the Nominee age is less than 18 years): Appointee Name, Relationship with Minor, Age, Mobile No., Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Tenure: As per Base Policy","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Cover Type: As per Base Policy","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous or Existing Health Insurance Details","fields":[{"help":"","type":"yes-no","label":"Have any of the person(s) to be insured ever filed a claim with their current/ previous insurer? If Yes, please provide details on a separate sheet","options":["Yes","No"],"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":["Yes","No"],"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":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill start date of previous insurance for each insured","type":"table","label":"Details of Previous or Existing Health Insurance: Since (DD/MM/YYYY) for each insured person","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"Select payment mode","type":"choice","label":"Payment By: Cash / Cheque / Demand Draft / Card / ECS (NACH) / Reward Points / Wallet / Any other mode (Strike out whichever is not applicable)","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)","Reward Points","Wallet","Any other mode"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Premium payment mode: As per base Policy","options":[],"required":true,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Cheque / Demand Draft No. / Authorization ID :","options":[],"required":false,"pdf_field":""},{"help":"Fill amount paid","type":"amount","label":"Payment Amount (`) :","options":[],"required":true,"pdf_field":""},{"help":"Fill premium amount","type":"amount","label":"Premium Amount (`) :","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Fill if applicable","type":"text","label":"Bank Name :","options":[],"required":false,"pdf_field":""},{"help":"Tick as applicable","type":"choice","label":"UPI-Mandate Confirmation: Yes, No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"NEFT Details (for claims & refund purposes)","fields":[{"help":"Provide bank account number","type":"text","label":"Account Number :","options":[],"required":true,"pdf_field":""},{"help":"Provide IFSC code","type":"text","label":"IFSC Code :","options":[],"required":true,"pdf_field":""},{"help":"Provide bank name","type":"text","label":"Bank Name :","options":[],"required":true,"pdf_field":""},{"help":"Provide branch name","type":"text","label":"Bank Branch Name :","options":[],"required":false,"pdf_field":""},{"help":"Provide account holder name","type":"text","label":"Name of the Account Holder :","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque copy","type":"attachment","label":"Please submit copy of cancelled cheque along with Proposal Form","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Proposer /Authorized Representative* :","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place :","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"health insurance proposals for Care Advanced policy","attachments":["All attached documents form part of this Proposal Form","Copy of cancelled cheque along with Proposal Form"],"declarations":["The proposer declares that all information given is true and complete to the best of their knowledge.","The proposer authorizes the company to seek medical and other information for underwriting and claims.","The proposer agrees that non-disclosure of material facts may lead to policy being void and premiums forfeited.","The agent declares that the proposal form contents have been explained to the proposer.","The proposer consents to premium payment and policy issuance terms as per company underwriting policy."],"dropped_labels":6},"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/2652-proposal-form"}