{"id":2675,"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-supreme---proposal-form.pdf","sha256":"0d916c7555476125e67a55d67e2267a0d865beb74bbc443becca809a38485ea7","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities proposing to purchase a health insurance policy from Care Health Insurance Limited. The proposer fills this form to provide personal, nominee, health, and policy details for underwriting and policy issuance.","notes":["The registered mobile number will be enrolled for WhatsApp notifications related to your Care Health Insurance Policy","If you want to provide more than 3 nominees, provide a separate application or add nominee via website through Endorsement","Use last 4 digits of Aadhaar number where requested","Provide details of any previous health insurance claims or proposal declines on a separate sheet","Attach original medical documents wherever applicable","Optional covers are detailed in Annexure I","Fill all dates in DD/MM/YYYY format"],"title":"Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Intermediary Details","fields":[{"help":"","type":"text","label":"Intermediary Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Intermediary RM Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Customer Acc No. :","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Care Health Insurance Branch Details","fields":[{"help":"","type":"text","label":"CHI RM Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch Code :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Client ID :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Receipt ID :","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of ‘Point of Sales’ Person","fields":[{"help":"Provide at least one of the following details if policy sourced through Point of Sales person","type":"text","label":"Aadhar Card No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN Card No.:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proof of Identity (POI)","fields":[{"help":"Tick whichever is applicable","type":"checkbox","label":"PAN","options":["PAN"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Aadhaar","options":["Aadhaar"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Passport","options":["Passport"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Driving License","options":["Driving License"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Voter ID Card","options":["Voter ID Card"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Letter from a recognized public authority or public servant verifying the identity and residence of the Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proof of Address (POA)","fields":[{"help":"Tick whichever is applicable","type":"checkbox","label":"Electricity bill (not older than 3 months)","options":["Electricity bill (not older than 3 months)"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Aadhaar","options":["Aadhaar"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Passport","options":["Passport"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Ration Card","options":["Ration Card"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Driving License","options":["Driving License"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Telephone Bill (not older than 3 months)","options":["Telephone Bill (not older than 3 months)"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Bank Account Statement (not older than 3 months)","options":["Bank Account Statement (not older than 3 months)"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Letter from a recognized public authority or public servant verifying the identity and residence of the Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Proposer Details","fields":[{"help":"Enter full name with title","type":"text","label":"Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":true,"pdf_field":""},{"help":"Enter full correspondence address","type":"text","label":"Correspondence Address : Locality","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Village","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Gram Panchayat","options":[],"required":false,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin 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Number","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":"text","label":"Aadhaar Number (last 4 digits)","options":[],"required":false,"pdf_field":""},{"help":"Customer KYC number","type":"text","label":"CKYC","options":[],"required":false,"pdf_field":""},{"help":"Sign to give consent","type":"signature","label":"By signing the Proposal form I give my consent for using my Aadhaar No. for Authentication of my Aadhaar Details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"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":"Details of the Proposed to be Insured including Proposer","fields":[{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Divorced","Widow(er)","Separated"],"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","Others"],"required":true,"pdf_field":""},{"help":"Provide if available","type":"text","label":"Aadhaar/PAN No. (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Name of nominee for this insured","type":"text","label":"Nominee","options":[],"required":false,"pdf_field":""},{"help":"Relationship of insured with proposer","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"","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":"If yes, provide ABHA Number (optional)","type":"yes-no","label":"Do you have ABHA No.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If applicable for differently abled persons","type":"number","label":"Specify the percentage of impairment","options":[],"required":false,"pdf_field":""},{"help":"If yes, enclose disability certificate mentioning percentage of disability","type":"yes-no","label":"Do you fall under the category of Differently Abled Persons?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"UDID number for differently abled persons","type":"text","label":"Please enter the Unique Disability ID (UDID) Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"DD/MM/YYYY 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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":""}],"filled_by":"proposer"},{"title":"Appointee Details (Only where the Nominee age is less than 18 years)","fields":[{"help":"Name of appointee for minor nominee","type":"text","label":"Appointee Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Minor","options":[],"required":false,"pdf_field":""},{"help":"","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":"Medical / Lifestyle Related Information","fields":[{"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, have symptoms or complaints needing doctors consultation, been advised or had been hospitalized for more than 5 days in total, or undergone any surgery in the last 12 months?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide 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":""},{"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":""},{"help":"Provide details of other pre-existing diseases","type":"text","label":"Additional Information (If your answer is 'Yes' to any of the above questions or the proposed to be insured are suffering from any other pre-existing disease which is not mentioned in the above list)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"Bank account number for premium payment","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":"Name of bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Branch of bank","type":"text","label":"Bank Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Name as per bank account","type":"text","label":"Name of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Previous or Existing Health Insurance","fields":[{"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":"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":""}],"filled_by":"proposer"},{"title":"Optional Covers (Annexure - I)","fields":[{"help":"","type":"yes-no","label":"Optional Cover – 1 : Smart Select","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 2 : Room Rent Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention modified number of months","type":"yes-no","label":"Optional Benefit – 3 : PED Wait Period Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, mention modified number of months","type":"yes-no","label":"Optional Benefit – 4 : Named Ailment Wait Period Modification","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 5 : Instant Cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, mention the deductible amount opted","type":"yes-no","label":"Optional Benefit – 6 : Deductible","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, mention the Co-pay %","type":"yes-no","label":"Optional Benefit – 7 : Co-Payment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 8 : New Born cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 9 : Plus Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 10 : Cumulative Bonus Super","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 11 : Annual Health checkup","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 12 : Be-Fit Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 13 : Wellness Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 14 : Air Ambulance Cover","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 15 : Women Care benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 16 : Mental Health wellbeing","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 17 : Claim Shield","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 18 : Unlimited Care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 19 : True Connect","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit – 20 : Health Management Program","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health insurance proposals for Care Health Insurance Limited policies","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 wherever applicable"],"declarations":["By signing the Proposal form I give my consent for using my Aadhaar No. for Authentication of my Aadhaar Details","I hereby give my consent and authorize Care Health Insurance Limited to block the payable premium amount and debit the same from my Bank Account under Bima-ASBA facility on acceptance of my Proposal","The Company shall reject Your proposal and refund the premium amount (after deducting cost of medical tests, if any) in case of incompleteness or any discrepancy highlighted or any other reason","In event of the death of the proposer any payment due under the policy shall become payable to the Nominee proposed in this form and receipt by the Nominee/Beneficiary is sufficient discharge to the Company","Prohibition of Rebates: No person shall offer or accept any rebate of commission or premium except as allowed by published prospectuses or tables of the Insurer"],"dropped_labels":9},"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/2675-proposal-form"}