{"id":2653,"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/ultimate-care-----proposal-form.pdf","sha256":"c3db638a0b255326212a21b466d6eb6648529995fd376a485f6adeed7ff8cdc8","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities (Proposers) to apply for health insurance coverage under the Ultimate Care plan offered by Care Health Insurance Limited. The Proposer fills this form to provide personal, nominee, insured persons' details, medical history, and payment information.","notes":["Fill the form in CAPITAL LETTERS only.","If insufficient space, use the Additional Information section.","Attach all relevant documents as part of the proposal.","Premium payment by cash should be done only at authorized branches with computerized receipt.","Total percentage of claim amount payable to nominees must not exceed 100%.","If applying for portability, fill separate Portability Form.","For premium payment through ECS, submit standing instruction form available at branches.","Use block letters and provide accurate contact details.","Attach disability certificate if applicable for differently abled persons.","Keep acknowledgement receipt for records; it does not confirm policy acceptance.","Agent must explain the form contents and consequences of untrue information to proposer.","Vernacular declaration required if proposer cannot read/write or has disability restricting writing."],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Provide your current mailing address","type":"text","label":"Correspondence Address : Locality, City, Pin Code, State, Landmark","options":[],"required":true,"pdf_field":""},{"help":"Provide permanent address or tick if same as correspondence","type":"text","label":"Permanent Address : If same as above, please tick here; else Locality, City, Village, Gram Panchayat","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status : Single, Married, Divorced, Widow(er), Separated","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":true,"pdf_field":""},{"help":"Alternate contact number","type":"phone","label":"Alternate No.","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":true,"pdf_field":""},{"help":"Landline number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number for WhatsApp notifications","type":"phone","label":"Mobile*","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":"choice","label":"Gender : Male, Female, Others","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Mother’s Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"CKYC: 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":"number","label":"Aadhaar Number (last 4 digits)","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"Select one or more valid identity proofs","type":"checkbox","label":"Proof of Identity (POI) (Tick whichever is applicable)","options":["Letter from a recognized public authority or public servant verifying the identity and residence of the Proposer","Electricity bill (not older than 3 months)","Aadhaar","Passport","Ration Card","Driving License","PAN","Voter ID Card"],"required":true,"pdf_field":""},{"help":"Select one or more valid address proofs","type":"checkbox","label":"Proof of Address (POA) (Tick whichever is applicable)","options":["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","Aadhaar","Passport","Driving License","Voter ID Card"],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Nominee Details","fields":[{"help":"Total must not exceed 100%","type":"number","label":"Specify the percentage (%) of the claim amount payable to each nominee","options":[],"required":true,"pdf_field":""},{"help":"Nominee's correspondence address or tick if same as proposer","type":"text","label":"Correspondence Address (If same as Proposer please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Nominee's permanent address or tick if same as proposer","type":"text","label":"Permanent Address (If same as Proposer please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Nominee's mobile number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Nominee's email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Nominee's bank account number","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":"Name of bank","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Account holder's name","type":"text","label":"Name of the Account Holder","options":[],"required":false,"pdf_field":""},{"help":"Fill if nominee is minor","type":"text","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":"choice","label":"Cover Type : Individual, Floater","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Tenure : 1 Year, 2 Years, 3 Years, 4 Years, 5 Years","options":["1 Year","2 Years","3 Years","4 Years","5 Years"],"required":true,"pdf_field":""},{"help":"If yes, fill separate Portability Form","type":"yes-no","label":"Are you applying for portability? Yes, No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Refer Annexure I for optional covers","type":"text","label":"Details of Optional Cover(s) as per Annexure - I","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","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":"Provide eIA details if available","type":"text","label":"If you have an eIA, please provide following details: Name of Insurance Repository, eIA No, Name as appearing in eIA","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to open eIA account","type":"yes-no","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":"yes-no","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":""}],"filled_by":"Proposer"},{"title":"Medical / Lifestyle Related Information","fields":[{"help":"","type":"yes-no","label":"Does any person(s) to be insured have any pre-existing diseases or is on any medication? If yes, provide details in additional information section","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide lifestyle habits details","type":"text","label":"Do you smoke, consume alcohol, or chew tobacco, ghutka or paan? Provide frequency, type, volume, unit of measure, since when","options":[],"required":false,"pdf_field":""},{"help":"Provide details in additional information if Yes","type":"yes-no","label":"Have you had any adverse finding to any diagnostic test or procedures, symptoms needing doctor consultation, hospitalization for more than 5 days, or surgery in last 12 months?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Use this section to provide further details","type":"text","label":"Additional Information (if your answer is 'Yes' to any above questions or suffering from any other pre-existing disease not mentioned)","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) (Strike out whichever is not applicable)","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)"],"required":true,"pdf_field":""},{"help":"Provide cheque/DD number or authorization ID if applicable","type":"text","label":"Cheque / Demand Draft No. / Authorization ID","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of bank for payment","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Payment Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Premium amount","type":"amount","label":"Premium Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Select premium payment frequency","type":"choice","label":"Premium payment mode: Single, Monthly, Quarterly, Half-yearly (Tick whichever is applicable)","options":["Single","Monthly","Quarterly","Half-yearly"],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Details of Previous or Existing Health Insurance","fields":[{"help":"Provide start date of previous policies","type":"date","label":"Details of previous or existing health insurance policies for each insured: Since (DD/MM/YYYY)","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"}],"deadlines":[],"applies_to":"Ultimate Care health insurance proposal","attachments":["Proof of Identity documents","Proof of Address documents","Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test","Copy of cancelled cheque for bank details"],"declarations":["I declare that the information provided is true and complete to the best of my knowledge.","I consent to the company sharing my proposal and medical information for underwriting and claims settlement.","I will notify any change in occupation or health after submission but before acceptance.","I understand the policy will come into force only after full payment of premium.","I authorize the company to seek medical information from doctors, hospitals, employers, and insurers as needed.","I understand that untrue statements or non-disclosure may lead to policy cancellation and forfeiture of premiums."],"dropped_labels":20},"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/2653-proposal-form"}