{"id":2664,"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-saksham---proposal-form.pdf","sha256":"0a318bd7794fb8d22d51f715029b8de9322537ae5512e5abe86427a4385557db","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by persons with disability, mental illness, or HIV/AIDS to apply for the Care Saksham insurance policy. The proposer (applicant) fills it out with personal, health, and nominee details.","notes":["Only Indian Nationals can be covered under this policy","Persons with Disability must have 40% or more disability certified by government Medical Board as per Disability Act 2016","Use original documents for proof of identity and address","If paying premium 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 deposited cash will not be admitted","If paying by cheque/demand draft, instrument should be drawn in favour of 'Care Health Insurance Ltd.'","If proposer is person with disability and appoints authorized representative, signature of authorized representative is required","Total percentage of claim amount payable to nominees must not exceed 100%","If more than 3 nominees, provide separate application or add via website endorsement","Section 41 of Insurance Act 1938 prohibits rebating; violation may lead to fine up to Rupees Ten Lakhs"],"title":"Proposal Form","submit":{"to":"Care Health Insurance Limited","how":"post / in person / upload (not explicitly stated)","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":"","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":null,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Village","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Gram Panchayat","options":[],"required":null,"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":"choice","label":"Profession","options":["Salaried","Self-Employed","Other"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Details: Occupation and Nature of Business/Work","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number or Form 60/61","type":"text","label":"PAN No./ form 60/61","options":[],"required":false,"pdf_field":""},{"help":"Last 4 digits only","type":"number","label":"Aadhaar Number(last 4 digits)","options":[],"required":false,"pdf_field":""},{"help":"Central KYC registry number","type":"text","label":"CKYC","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number for WhatsApp notifications","type":"phone","label":"Phone*","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"","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":"","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":true,"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","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy Type","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy period","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Period of Insurance: From","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Sum Insured","options":["` 400,000","` 500,000"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Coverage opted","options":["Pre-existing HIV/AIDS","Pre-existing Disability","Pre-existing HIV/AIDS and Disability"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Persons to be Insured","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"in cm","type":"number","label":"Height","options":[],"required":false,"pdf_field":""},{"help":"in kg","type":"number","label":"Weight","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Marital Status","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relation with Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Waiver of co-payment","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Deductible Option","options":[],"required":false,"pdf_field":""},{"help":"If Yes, provide ABHA Number (Optional)","type":"yes-no","label":"Do you have ABHA No.","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Up to 3 nominees","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"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":"","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":"Name, Relationship with Minor, Age, Mobile No., Email ID","type":"text","label":"Appointee Details (Only where the Nominee age is less than 18 years)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Details of Insured","fields":[{"help":"If Yes, enclose recent CD4 count certificate (within past 30 days)","type":"yes-no","label":"Do you suffer from HIV/AIDS?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Current CD 4 count","options":[],"required":false,"pdf_field":""},{"help":"If yes, specify when and how many times","type":"yes-no","label":"Has your CD4 Count gone below 500 in the past 4 years?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Do you suffer from any other illness/disease related to/ arising of/ associated to HIV/AIDS?","options":[],"required":false,"pdf_field":""},{"help":"If Yes, enclose Disability certificate mentioning percentage","type":"yes-no","label":"Do you suffer from any disability as per the listed conditions (Blindness, Muscular Dystrophy, Low vision, Chronic Neurological conditions, Leprosy Cured persons, Specific Learning Disabilities, Hearing Impairment, Multiple Sclerosis, Locomotor Disability, Speech and Language disability, Dwarfism, Thalassemia, Intellectual Disability, Haemophilia, Mental Illness, Sickle Cell disease, Autism spectrum disorder, Multiple Disabilities including deaf/blindness, Cerebral Palsy, Acid Attack victim, Parkinson's disease)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, specify details","type":"yes-no","label":"Do you suffer from any pre-existing illness other than Disability or HIV AIDS mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical / Lifestyle Related Information","fields":[{"help":"If yes, provide details in additional information section","type":"yes-no","label":"Does any person(s) to be insured have any pre-existing diseases or is on any medication?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Cancer/Tumor/Cyst/Polyp (Any Type of Growth in/on Body)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"High cholesterol/ Hyperlipidemia or Cardiovascular or Heart Disease or undergone heart treatment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Hypertension / High Blood Pressure?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Respiratory Disorder (Asthma/ COPD/ Bronchitis/ lung disease, etc.)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Disease of the Brain / Neurological Disorder / Spinal Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Mental Illness (Psychiatric Disorder)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Pancreatitis or Liver disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Kidney / Urinary track / Reproductive Organ Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Blood Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Autoimmune Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","type":"yes-no","label":"Sexually Transmitted Disease (STDs)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify since when if Yes","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":"Specify since when if Yes","type":"yes-no","label":"Any other disease/ health adversity/ injury/ condition/ treatment not mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details in additional information section","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? (Excludes common cold, cough, flu, acute respiratory tract infection or pregnancy)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details in additional information section","type":"yes-no","label":"Have you had any adverse finding to any diagnostic test or procedures, symptoms needing doctors consultation, been advised or hospitalized for more than 5 days, or undergone surgery in last 12 months?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify details if Yes","type":"text","label":"Do you smoke, consume alcohol, or chew tobacco, ghutka or paan? Alcohol: Frequency, Type, Volume, Unit of Measure","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Details","fields":[{"help":"","type":"text","label":"Name of Premium payer","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Premium Payment Frequency","options":["Monthly","Quarterly","Half Yearly","Single"],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Premium Amount (in `)","options":[],"required":true,"pdf_field":""},{"help":"Specify if Others","type":"choice","label":"Instrument Type","options":["Cash","Cheque","Debit Card","Credit Card","Others"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"If payment by cheque","type":"text","label":"Cheque no.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Insurance Details","fields":[{"help":"","type":"yes-no","label":"Do you have the same policy from any one or other insurer? Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy No. / Application No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insurer Name","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY to DD/MM/YYYY","type":"text","label":"Period of Insurance (from – to)","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Claims lodged during the preceding years","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Account Details for Process of Refund","fields":[{"help":"","type":"text","label":"Name as in Bank Account","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""},{"help":"If applicable","type":"text","label":"Cheque No","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Cheque Date","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Declaration","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Licence No.","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Proposer Declaration & Signature","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Only if proposer is person with disability and has authorized representative","type":"signature","label":"Signature of proposer/ Authorized Representative*","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"AML Guidelines Declaration","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"One-Time Mandate Bima-ASBA","fields":[{"help":"Tick whichever is applicable","type":"choice","label":"UPI-Mandate Confirmation","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Vernacular Declaration","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature/Thumb impression of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":["Proposal is not covered until accepted and premium is paid and realized by Care Health Insurance Limited","Submit recent CD4 count certificate within past 30 days if HIV/AIDS positive"],"applies_to":"Persons with Disability, Mental Illness and Persons with HIV/AIDS","attachments":["Proof of Identity (POI) document","Proof of Address (POA) document","Disability certificate mentioning percentage of disability (if applicable)","Recent certificate of current CD4 count (within past 30 days) if HIV/AIDS positive","Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test","Cancelled Cheque for bank account refund process"],"declarations":["The proposer declares all information is true and complete to the best of their knowledge","The policy will come into force only after full receipt of premium","The proposer will notify any change in occupation or health after submission but before risk acceptance","The company may seek medical information from hospitals, employers, and other insurers for underwriting and claims","The company may share proposal and medical information with government and regulatory authorities including ABHA","The proposer is aware of premium loading for habits and diseases declared","The proposer agrees to keep KYC details of all insured members and provide beneficiary details when required","The agent declares having explained the proposal form contents to the proposer","The proposer confirms premiums are paid from bonafide sources and not from proceeds of crime","The proposer authorizes Care Health Insurance Limited to block and debit premium amount from bank account under Bima-ASBA facility"],"dropped_labels":7},"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/2664-proposal-form"}