{"id":2655,"title":"Supreme Enhance - 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/supreme-enhance---proposal-form.pdf","sha256":"9630fa69579b97711e7e9a3c5d67a89905ccc7a06eb5ffda7c0272502c78cb2c","pages":8,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities (Proposers) to apply for the Supreme Enhance health insurance policy from Care Health Insurance Limited. The Proposer fills it to provide personal, health, and policy details for underwriting.","notes":["Fill the form in CAPITAL LETTERS only.","Use additional information section if space is insufficient.","Attach all supporting documents as part of the proposal.","Use original bills and documents where applicable.","If paying premium by cash, do so only at nearest Care Health Insurance branch or authorized bank branch and obtain computerized receipt.","Total percentage of claim amount payable to nominees must not exceed 100%.","If proposer is a person with disability and has appointed an authorized representative, sign accordingly.","For portability, fill separate Portability Form.","If proposer cannot read/write or signed in vernacular language or has disability restricting writing, use Vernacular Declaration."],"title":"Supreme Enhance - Proposal Form","submit":{"to":"Care Health Insurance Limited branch or authorized Bank branch","how":"in person or by post","address":"Registered Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019; Correspondence Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43, Gurugram-122009 (Haryana)"},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter proposal number if available","type":"text","label":"Proposal No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"URN:","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Name : (Mr./Ms./Mrs.)","options":["Mr.","Ms.","Mrs."],"required":true,"pdf_field":""},{"help":"Enter first name in capital letters","type":"text","label":"(First Name)","options":[],"required":true,"pdf_field":""},{"help":"Enter middle name if any","type":"text","label":"(Middle Name)","options":[],"required":false,"pdf_field":""},{"help":"Enter last name in capital letters","type":"text","label":"(Last Name)","options":[],"required":true,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Permanent Address :","options":[],"required":true,"pdf_field":""},{"help":"Tick if correspondence address is same as permanent","type":"checkbox","label":"If same as above, please tick here","options":[],"required":false,"pdf_field":""},{"help":"Enter full correspondence address","type":"text","label":"Correspondence Address :","options":[],"required":true,"pdf_field":""},{"help":"Enter landline number if any","type":"phone","label":"Landline (Residence)  :","options":[],"required":false,"pdf_field":""},{"help":"Enter office phone number if any","type":"phone","label":"Office :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number for WhatsApp notifications","type":"phone","label":"Mobile No . :","options":[],"required":true,"pdf_field":""},{"help":"Alternate contact number","type":"phone","label":"Alternate No :","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth or incorporation","type":"date","label":"Date of Birth / Incorporation (in case Proposer is an entity) :","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender :","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email :","options":[],"required":false,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status :","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"Select nationality","type":"choice","label":"Nationality :","options":["Indian","Other than Indian"],"required":true,"pdf_field":""},{"help":"Select if Form 60 is submitted","type":"choice","label":"CKYC Form 60 (only in case the customer does not have PAN no.) :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar","type":"text","label":"Aadhaar Number (last 4 digits) :","options":[],"required":false,"pdf_field":""},{"help":"Enter mother's name","type":"text","label":"Mother’s Name :","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Policy Details","fields":[{"help":"Select cover type","type":"choice","label":"Cover Type :","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":"Select policy tenure","type":"choice","label":"Tenure :","options":["1 Year","2 Year","3 Year"],"required":true,"pdf_field":""},{"help":"If yes, fill separate Portability Form","type":"yes-no","label":"Are you applying for portability?","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":""}],"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 in the event of the policyholder’s death","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Details of Proposed Insured Persons","fields":[{"help":"If yes, provide ABHA Number (optional)","type":"yes-no","label":"Do you have ABHA No.? (Y/N)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter nominee name","type":"text","label":"Nominee","options":[],"required":false,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"Enter city","type":"text","label":"City of Residence","options":[],"required":false,"pdf_field":""},{"help":"Politically Exposed Person status","type":"yes-no","label":"If PEP*","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"If yes, enclose disability certificate and specify percentage","type":"yes-no","label":"Do you fall under the category of Differently Abled Persons?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter UDID number if applicable","type":"text","label":"Unique Disability ID (UDID) Number","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Plan and Optional Benefits Selection","fields":[{"help":"Select sum insured option","type":"choice","label":"Plan A Sum Insured Options 1","options":["30 Lac","40 Lac","43 lac","45 lac","50Lac","60 lac","75 Lac","85 lac","90 Lac","93 lac","95 Lac","1 Cr","1.25 Cr","1.5 Cr","2Cr","6Cr"],"required":true,"pdf_field":""},{"help":"Select deductible option","type":"choice","label":"Plan A Deductible Options 1","options":["3lac","5 lac","7 Lac","10 Lac","15 lac","20Lac","25Lac"],"required":true,"pdf_field":""},{"help":"Select second sum insured option if applicable","type":"choice","label":"Plan A Sum Insured Options 2","options":["5 Lac","10Lac","15 Lac","20 Lac","25 Lac"],"required":false,"pdf_field":""},{"help":"Select second deductible option if applicable","type":"choice","label":"Plan A Deductible Options 2","options":["1 lac","2 lac","3 lac","4 lac","5 lac"],"required":false,"pdf_field":""},{"help":"Enter deductible amount for room rent/associated medical expenses","type":"amount","label":"Benefit 1: Proportionate Charges Cover (Plan B)","options":[],"required":false,"pdf_field":""},{"help":"Enter deductible amount for cataract treatment","type":"amount","label":"Benefit 2: Cataract Treatment (Plan B)","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","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":"Provide Insurance Repository name, eIA No, and Name as appearing in eIA","type":"text","label":"If you have an eIA, please provide following details:","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"If you do not have an eIA, would you like to open an account?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","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":"Medical / Lifestyle Related Information","fields":[{"help":"Answer for each insured person","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","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Cancer/Tumor/Cyst/Polyp (Any Type of Growth in/on Body)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"High cholesterol/Hyperlipidemia or Cardiovascular or Heart Disease or undergone heart treatment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Hypertension / High Blood Pressure?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Respiratory Disorder (Asthma/ COPD/ Bronchitis/ lung disease, etc.)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Thyroid Disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Was Malignancy detected?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Have taken or currently on insulin?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Any complications caused by diabetes?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Diabetes (High Blood Sugar)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Disease of the Brain / Neurological Disorder / Spinal Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Mental Illness (Psychiatric Disorder)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Pancreatitis or Liver disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Kidney / Urinary track / Reproductive Organ Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Blood Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Autoimmune Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Sexually Transmitted Disease (STDs)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Obesity/High BMI, Any disease/health/adversity/injury/condition/treatment not mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Exclude visits for common cold, flu, pregnancy","type":"yes-no","label":"Have you consulted a doctor or a health professional four or more times during the last six months or have any follow-up in the upcoming year?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Have you had any adverse finding to any diagnostic test or procedures, symptoms needing doctors consultation, hospitalization for more than 5 days, or surgery in last 12 months?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Do you smoke, consume alcohol, or chew tobacco, ghutka or paan?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach relevant medical documents","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":"Details of Previous or Existing Health Insurance","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":["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 Care Health Insurance?","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":"Enter date since insured under previous policy","type":"date","label":"Since (DD/MM/YYYY)","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"help":"Enter bank account number for payouts","type":"text","label":"Account Number :","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code :","options":[],"required":true,"pdf_field":""},{"help":"Enter account holder name","type":"text","label":"Name of the Account Holder :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Bank Branch Name :","options":[],"required":false,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place :","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Premium Payment Information","fields":[{"help":"Strike out non-applicable modes","type":"choice","label":"Payment By:","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)","Reward Points","Wallet","Any other mode"],"required":true,"pdf_field":""},{"help":"Tick applicable mode","type":"choice","label":"Premium payment mode:","options":["Single","Monthly","Quarterly","Half-yearly"],"required":true,"pdf_field":""},{"help":"Enter cheque/DD number or authorization ID","type":"text","label":"Cheque / Demand Draft No. / Authorization ID :","options":[],"required":false,"pdf_field":""},{"help":"Enter payment date","type":"date","label":"Date :","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name for payment","type":"text","label":"Bank Name :","options":[],"required":false,"pdf_field":""},{"help":"Enter payment amount","type":"amount","label":"Payment Amount (`) :","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount","type":"amount","label":"Premium Amount (`) :","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Declarations and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place :","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Proposer/Authorized Representative* :","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Agent Declaration","fields":[{"help":"Enter date","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Signature :","options":[],"required":true,"pdf_field":""},{"help":"Enter license number","type":"text","label":"License No. (Advisor/Corporate Agent/Broker/Relationship Officer):","options":[],"required":true,"pdf_field":""},{"help":"Enter sales person name","type":"text","label":"SP Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter sales person code","type":"text","label":"SP Code :","options":[],"required":true,"pdf_field":""}],"filled_by":"Agent"},{"title":"Vernacular Declaration","fields":[{"help":"Enter declarant's name","type":"text","label":"Name of the Declarant :","options":[],"required":true,"pdf_field":""},{"help":"Declarant signature","type":"signature","label":"Signature of the Declarant :","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""}],"filled_by":"Declarant"}],"deadlines":[],"applies_to":"Health insurance proposals for Supreme Enhance policy","attachments":["Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test","Disability certificate mentioning percentage of disability (if applicable)"],"declarations":["The information given is true and correct to the best of my knowledge and I am authorized to propose on behalf of all persons insured.","The information provided forms the basis of the insurance policy and the policy will come into force only after full payment of premium.","I will notify in writing any change in occupation or health after submission but before acceptance of risk.","I consent to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claim settlement.","I authorize the company to share my proposal and medical records with government and regulatory authorities including ABHA.","I authorize Care Health Insurance Limited to directly credit payouts/refunds to the provided bank account and will not hold the company responsible for non-credit due to incorrect information.","I understand that any untrue statement or non-disclosure may lead to policy variation or nullification and forfeiture of premiums.","I consent to Bima-ASBA facility for blocking and debiting premium amount from my bank account upon acceptance of proposal."],"dropped_labels":22},"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/2655-supreme-enhance-proposal-form"}