{"id":2679,"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/arogya-sanjeevani-policy---care-health-insurance-(health-insurance-product)---proposal-form.pdf","sha256":"4c25e47e7f15d44cea25d8274500f1d7d0c97c650695907cbe2cf914ebe8e4d4","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities proposing to purchase the Arogya Sanjeevani Health Insurance policy from Care Health Insurance Limited. The proposer fills it to provide personal, nominee, insured persons, medical, and payment details for underwriting and policy issuance.","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.","Payment by cash should be made only at nearest Care Health Insurance branch or authorized bank branch with computerized receipt.","Any claim without computerized receipt against deposited cash will not be admitted.","Total percentage of contribution across all nominees must not exceed 100%.","If proposer is a person with disability and has appointed an authorized representative, certain declarations apply.","The form includes a statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938.","The acknowledgement receipt is not acceptance of risk or commencement of policy.","Acceptance of proposal and issuance of policy is subject to underwriting decision and receipt of premium and medical reports."],"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":"Point of Sales Person Details","fields":[{"help":"Provide Aadhaar number of Point of Sales person if applicable","type":"text","label":"Aadhaar Card No.","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN number of Point of Sales person if applicable","type":"text","label":"PAN Card No.","options":[],"required":false,"pdf_field":""},{"help":"Tick whichever is applicable","type":"choice","label":"Proof of Address (POA)","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","Telephone Bill (not older than 3 months)","Bank Account Statement (not older than 3 months)"],"required":false,"pdf_field":""},{"help":"Tick whichever is applicable","type":"choice","label":"Proof of Identity (POI)","options":["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":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Proposer Details","fields":[{"help":"Fill in capital letters","type":"text","label":"First Name","options":[],"required":true,"pdf_field":""},{"help":"Fill in capital letters","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":""},{"help":"Fill in capital letters","type":"text","label":"Last Name","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"State of residence","type":"text","label":"State","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":"Provide valid email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Mother’s Name","options":[],"required":false,"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":"DD/MM/YYYY format","type":"date","label":"Date of Birth / Incorporation (in case Proposer is an entity)","options":[],"required":true,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"Prefix title","type":"text","label":"Name: (Mr./Ms./Mrs.)","options":[],"required":true,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Marital Status","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Central Know Your Customer number","type":"text","label":"CKYC","options":[],"required":false,"pdf_field":""},{"help":"Fill full permanent address","type":"text","label":"Permanent Address","options":[],"required":true,"pdf_field":""},{"help":"Tick if correspondence address is same as permanent address","type":"checkbox","label":"If same as above, please tick here","options":[],"required":false,"pdf_field":""},{"help":"Locality of correspondence address","type":"text","label":"Locality","options":[],"required":false,"pdf_field":""},{"help":"City of correspondence address","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Fill full correspondence address if different","type":"text","label":"Correspondence Address","options":[],"required":false,"pdf_field":""},{"help":"Landmark near correspondence address","type":"text","label":"Landmark","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","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":""}],"filled_by":"Proposer"},{"title":"Policy Details","fields":[{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Select policy tenure","type":"choice","label":"Tenure","options":["1 Year"],"required":true,"pdf_field":""},{"help":"Select cover type","type":"choice","label":"Cover Type","options":["Individual","Floater"],"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":"If you have an eIA, provide repository name","type":"text","label":"Name of Insurance Repository","options":[],"required":false,"pdf_field":""},{"help":"Provide e-Insurance Account number","type":"text","label":"eIA No","options":[],"required":false,"pdf_field":""},{"help":"Provide name as in eIA","type":"text","label":"Name as appearing in eIA","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","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 one repository","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":"Tick applicable","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":"Name of nominee","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":"Relationship to proposer","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":"checkbox","label":"Correspondence Address (If same as Proposer please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Tick if same as proposer","type":"checkbox","label":"Permanent Address (If same as Proposer please tick here)","options":[],"required":false,"pdf_field":""},{"help":"Mobile number of nominee","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Email of nominee","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Bank account for claim payout","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 name","type":"text","label":"Name of the Account Holder","options":[],"required":false,"pdf_field":""},{"help":"Provide Appointee Name, Relationship with Minor, Age, Mobile No., Email ID","type":"table","label":"Appointee Details (Only where the Nominee age is less than 18 years)","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Details of the Proposed to be Insured Including Proposer","fields":[{"help":"Name of insured person","type":"text","label":"Name (Mr./Ms./Mrs.)","options":[],"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":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender","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":"Relationship to proposer","type":"text","label":"Relationship with Insured","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","type":"yes-no","label":"Do you have ABHA No.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide ABHA number if yes","type":"text","label":"If Yes, please provide ABHA Number (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable and enclose disability certificate if yes","type":"yes-no","label":"Do you fall under the category of Differently Abled Persons?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide percentage of disability","type":"number","label":"Specify the percentage of impairment","options":[],"required":false,"pdf_field":""},{"help":"Provide UDID number if applicable","type":"text","label":"Please enter the Unique Disability ID (UDID) Number","options":[],"required":false,"pdf_field":""},{"help":"Politically Exposed Person status","type":"yes-no","label":"If PEP*","options":["Yes","No"],"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":"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":"If yes, provide details and since when","type":"yes-no","label":"Cancer/Tumor/Cyst/Polyp (Any Type of Growth in/on Body)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details and since when","type":"yes-no","label":"High cholesterol/Hyperlipidemia or Cardiovascular or Heart Disease or undergone heart treatment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details and since when","type":"yes-no","label":"Hypertension / High Blood Pressure?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details and since when","type":"yes-no","label":"Respiratory Disorder (Asthma/ COPD/ Bronchitis/ lung disease, etc.)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide type of disease and medicine name","type":"yes-no","label":"Thyroid Disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Was Malignancy detected?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Diabetes (High Blood Sugar)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Any complications caused by diabetes?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Have taken or currently on insulin?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Disease of the Brain / Neurological Disorder / Spinal Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Mental Illness (Psychiatric Disorder)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide type, frequency, volume, and unit of measure","type":"yes-no","label":"Pancreatitis or Liver disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details for each type: frequency, type, quantity, volume, since when","type":"yes-no","label":"Do you smoke, consume alcohol, or chew tobacco, ghutka or paan?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Autoimmune Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Sexually Transmitted Disease (STDs)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Blood Disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide since when","type":"yes-no","label":"Kidney / Urinary track / Reproductive Organ Disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes, provide details","type":"yes-no","label":"Any other disease/ health adversity/ injury/ condition/ treatment not mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Exclude visits for common cold, cough, flu, acute respiratory tract infection or 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":"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":""}],"filled_by":"Proposer"},{"title":"Additional Information","fields":[{"help":"Provide details of any 'Yes' answers or other pre-existing conditions","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":"Strike out whichever is not applicable","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 whichever is applicable","type":"choice","label":"Premium payment mode","options":["Single","Monthly","Quarterly","Half-yearly"],"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":"Enter payment amount in rupees","type":"amount","label":"Payment Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Enter premium amount in rupees","type":"amount","label":"Premium Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","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":""}],"filled_by":"Proposer"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"help":"Bank account number for NEFT","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 name of bank","type":"text","label":"Bank Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Name of account holder","type":"text","label":"Name of the Account Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Attending Physician's Details","fields":[{"help":"Name of family doctor","type":"text","label":"Name of Family Physician","options":[],"required":false,"pdf_field":""},{"help":"Phone number of physician","type":"phone","label":"Contact Number","options":[],"required":false,"pdf_field":""},{"help":"Email of physician","type":"email","label":"Email","options":[],"required":false,"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":"If yes, provide details","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":"Provide details for each insured person including since when","type":"table","label":"Details","options":[],"required":false,"pdf_field":""}],"filled_by":"Proposer"},{"title":"Declarations and Authorizations","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","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":"Agent's full name","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Agent license number","type":"text","label":"License No. (Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent 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"},{"title":"Addendum – Vernacular Declaration","fields":[{"help":"Name of person explaining form in vernacular language","type":"text","label":"Name of the Declarant","options":[],"required":true,"pdf_field":""},{"help":"Place of declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Declarant","options":[],"required":true,"pdf_field":""}],"filled_by":"Declarant"},{"title":"One-Time Mandate BIMA-ASBA","fields":[{"help":"Tick applicable","type":"yes-no","label":"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.","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"Proposer"}],"deadlines":[],"applies_to":"Arogya Sanjeevani Policy - Care Health Insurance (Health Insurance Product)","attachments":["Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test wherever applicable","Copy of cancelled cheque along with Proposal Form","Disability certificate mentioning percentage of disability wherever applicable"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge.","The proposer consents to the company seeking medical information from doctors, hospitals, past or present employers, and insurers for underwriting and claim settlement.","The proposer will notify in writing any change in occupation or health after submission but before risk acceptance.","The company is authorized to share proposal and medical information with government and regulatory authorities including via ABHA.","The information provided forms the basis of the insurance policy which comes into force only after full premium payment.","The proposer authorizes direct credit of payouts/refunds to the provided bank account and accepts responsibility for accuracy of information.","Agent declares having explained the proposal form contents and consequences of untrue statements or non-disclosure.","Declarant confirms having explained the proposal form in vernacular language to the proposer who understood and confirmed the replies."],"dropped_labels":3},"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/2679-proposal-form"}