{"id":2665,"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-opd---proposal-form.pdf","sha256":"6ba36d5b860e34c942aaa46d5b312cd3c61f70e7d206860c63e70793401deff9","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer (individual or entity) to apply for a Care OPD health insurance policy with Care Health Insurance Limited.","notes":["Fill the form in CAPITAL LETTERS only.","If insufficient space, use the Additional Information section.","All attached documents form part of the Proposal Form.","If paying premium by cash, do so only at nearest Care Health Insurance branch or authorized bank branch and obtain computerized receipt.","Cheque/Demand Draft should be drawn in favour of 'Care Health Insurance Ltd.'","Submit standing instruction form if paying by ECS.","Provide copy of cancelled cheque for NEFT details.","Total percentage of claim amount payable to nominees must not exceed 100%.","If proposer is a person with disability and has authorized representative, signature of authorized representative is required.","For portability, fill separate Portability Form.","Use separate application or website endorsement to add more than 3 nominees."],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name in capital letters","type":"text","label":"Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":true,"pdf_field":""},{"help":"Enter date in 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":"Proposer's Insurance Details with Care Insurance - Name of Base Product","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Base Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Include locality, city, village, gram panchayat, pin code, state, landmark","type":"text","label":"Correspondence Address","options":[],"required":true,"pdf_field":""},{"help":"Tick if same as correspondence address","type":"text","label":"Permanent Address (If same as above, please tick here)","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number will be enrolled 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":"Provide PAN or Form 60 if PAN not available","type":"text","label":"PAN Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","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":"","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":"","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":"Select one proof of identity","type":"choice","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 one proof of address","type":"choice","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":"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 Repository Services Limited","KARVY Insurance Repository Limited","CIRL-Central Insurance Repository Limited (CDSL)"],"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","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Provide name of nominee(s)","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"Age of nominee","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Total across nominees 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":""},{"help":"Tick if same as proposer","type":"text","label":"Correspondence Address (If same as Proposer please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Tick if same as proposer","type":"text","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":"For payout/refund","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 of appointee if nominee is minor","type":"text","label":"Appointee Details (Only where the Nominee age is less than 18 years) - Appointee Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Minor","options":[],"required":false,"pdf_field":""},{"help":"Age of appointee","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"As per Base Policy","type":"text","label":"Tenure","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Cover Type","options":["Individual"],"required":true,"pdf_field":""},{"help":"Select Yes or No and mention amount if Yes","type":"amount","label":"Base Benefit: Physical Consultations with General Physicians (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No and mention amount if Yes","type":"amount","label":"Base Benefit: Physical Consultations with Specialists Doctors (Yes / No) (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No and mention amount if Yes","type":"amount","label":"Base Benefit: OPD Pharmacy (Yes / No) (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Refer Annexure I for optional benefits and amounts","type":"text","label":"Details of Optional Benefit(s) as per Annexure – I","options":[],"required":false,"pdf_field":""},{"help":"If yes, fill separate Portability Form","type":"yes-no","label":"Are you applying for portability?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"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":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"Strike out whichever is not applicable","type":"choice","label":"Payment By (Cash / Cheque / Demand Draft / Card /ECS (NACH)/Reward Points/Wallet/Any other mode)","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)","Reward Points","Wallet","Any other mode"],"required":true,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Enter payment amount in rupees","type":"amount","label":"Payment Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"If applicable","type":"text","label":"Cheque / Demand Draft No. / Authorization ID","options":[],"required":false,"pdf_field":""},{"help":"Date of payment instrument","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Previous or Existing Health Insurance","fields":[{"help":"If yes, provide details on a 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":"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":"For NEFT claims and refund purposes","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 Name","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":""}],"filled_by":"proposer"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"help":"Provide bank account number for payouts","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name","options":[],"required":true,"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":true,"pdf_field":""},{"help":"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":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Benefits (Annexure – I)","fields":[{"help":"","type":"yes-no","label":"Optional Benefit: Unlimited E-consultation","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Online Fitness Classes","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: OPD Physiotherapy (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: Psychologist Counseling (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: Preventive Health check-up (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: AYUSH Treatment (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: Dental Care (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Vision Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: Therapy Expenses (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: Medical Devices (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Mention amount if Yes","type":"amount","label":"Optional Benefit: OPD Diagnostic tests (If Yes, then please mention the amount opted)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Modification of Physical Consultations with General Physicians","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit: Modification of Physical Consultations with Specialist Doctors","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration for Agents","fields":[{"help":"Agent's full 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":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent's signature","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"}],"deadlines":[],"applies_to":"Care OPD health insurance policies","attachments":["Proof of Identity (POI)","Proof of Address (POA)","Copy of cancelled cheque"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the premium chargeable.","The proposer will notify in writing any change in occupation or health after submission but before risk acceptance.","The proposer consents to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claim settlement.","The proposer authorizes the company to share proposal and medical information with government and regulatory authorities including ABHA."],"dropped_labels":1},"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/2665-proposal-form"}