{"id":2683,"title":"explore® 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/explore-(travel-insurance-product)---proposal-form.pdf","sha256":"713117bcccb1fafe122051090b5fbe0aaba7c041a2f2f1756205dbd9449048fe","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities proposing to purchase the Explore Travel Insurance product from Care Health Insurance Limited. The proposer fills this form to provide personal, travel, and insurance details for underwriting and policy issuance.","notes":["Fill the form in CAPITAL LETTERS only.","If insufficient space, provide details on a separate sheet; all attachments form part of the proposal.","Registered mobile number will be enrolled for WhatsApp notifications.","Age for entry in individual cover type is minimum 2 days and maximum as per plan.","For payment by cash, pay 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.","Premium must be paid in advance as per Section 64VB of Insurance Act.","Attach copy of cancelled cheque for NEFT details.","Optional benefits and packages are not applicable for Domestic plan.","If proposer is a person with disability and has appointed an authorized representative, signature of authorized representative is required."],"title":"explore® Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name in capital letters","type":"text","label":"Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":true,"pdf_field":""},{"help":"If proposer is an entity, provide key person name","type":"text","label":"Key Person Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":false,"pdf_field":""},{"help":"Full mailing address","type":"text","label":"Correspondence Address :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Locality :","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":true,"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":"Nearby landmark","type":"text","label":"Landmark :","options":[],"required":false,"pdf_field":""},{"help":"Tick if permanent address is same as correspondence","type":"checkbox","label":"Permanent Address : If same as above, please tick here","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Telephone :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile will be enrolled for WhatsApp notifications","type":"phone","label":"Mobile :","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email :","options":[],"required":false,"pdf_field":""},{"help":"Date format DDMMYYYY","type":"date","label":"Date of Birth / Incorporation (in case Proposer is an entity) : DDMAYYY","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender : Male Female Others","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status Single Married Divorced Widow(er) Separated","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Mother's Name :","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Form 60 (only in case the customer does not have PAN no) : Yes 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":"Select at least one","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":"Select at least one","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":""}],"filled_by":"proposer"},{"title":"Electronic Policy Issuance (e-Insurance Account)","fields":[{"help":"","type":"choice","label":"Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (elA) of an Insurance Repository? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If you have an elA, please provide following details: Name of Insurance Repository:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"elANo:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name as appearing in elA:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If you do not have an elA, would you like to open an account? Yes No","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","CIRL-Central Insurance Repository Limited","KARVY"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Help us preserve the environment by opting to receive policy related information in soft copy/ via email only : Yes No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Date format DDMMYYYY","type":"date","label":"Proposed Policy Period Start Date : DDMMYYYY","options":[],"required":true,"pdf_field":""},{"help":"Date format DDMMYYYY","type":"date","label":"Proposed Policy Period End Date : DDMMYYYY","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Cover Type: Individual Multi-Individual Option","options":["Individual","Multi-Individual Option"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Trip Type:","options":["International Single Trip","International Annual Multi-trip (30 days)","International Annual Multi-trip (45days)","International Annual Multi-trip (60days)","International Annual Multi-trip (90days)","Domestic Single Trip (7days)","Domestic Single Trip (15days)","Domestic Single Trip (30days)","Domestic Single Trip (60days)","Domestic Single Trip (90days)","Domestic Annual Multi Trip (7days)","Domestic Annual Multi Trip (15days)","Domestic Annual Multi Trip (30days)"],"required":true,"pdf_field":""},{"help":"If Others, provide description","type":"choice","label":"Purpose of travel :","options":["Business","Adventure","Sports","Visit to Family/ Friends","Pleasure","Aviation","High altitude Pilgrimage","Others (if Others, Please provide the description)"],"required":true,"pdf_field":""},{"help":"Choose one plan","type":"choice","label":"Plan*","options":["Explore Platinum","Explore Gold","Explore Silver","Explore Asia","Explore ANZ","Explore Africa","Explore Canada+","Explore Europe","Explore Domestic"],"required":true,"pdf_field":""},{"help":"Choose sum insured corresponding to plan","type":"choice","label":"Sum Insured*","options":["Unlimited SI per incident limit of $ 1000,000","Unlimited SI per incident limit of $ 500,000","Unlimited SI per incident limit of $ 100,000","Unlimited SI per incident limit of $ 50,000","$ 1000,000","$ 750,000","$ 500,000","$300,000","$100,000","$ 50,000","$ 200,000","$100,000","$ 50,000","$ 25,000","$ 250,000","$ 200,000","$ 30,000","₹1000,000","₹500,000","₹100,000","₹50,000","₹25,000"],"required":true,"pdf_field":""},{"help":"Choose geographical scope corresponding to plan","type":"choice","label":"Geographical scope*","options":["Worldwide (Excluding India)","Worldwide(Excluding US, Canada and India)","Asia (Excluding India)","Thailand","Singapore & Malaysia","Japan","UAE","Maldives","Australia","New Zealand","Africa","Mauritius","Worldwide (Excluding US and India)","Europe","United Kingdom","India (Excluding City of Residence)"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Opt for Sub-limits","options":["Y","N"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Opt for Co-Pay","options":["Y","N","N.A.( No Co-pay restriction on this Plan by default)"],"required":false,"pdf_field":""},{"help":"List countries to be visited","type":"text","label":"Country(s) of visit (not applicable for Domestic plan): 2. 3. 4. 5. 6.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of the Persons to be Insured Including Proposer","fields":[{"help":"Full name in capital letters","type":"text","label":"Name : Mr./Ms./Mrs","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Single","Married","Divorced","Widow(er)","Separated"],"required":false,"pdf_field":""},{"help":"Date format DDMMYYYY","type":"date","label":"Date of Birth DDMMYYYY","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Passport No.(Not mandatory for Domestic plan) :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender Male Female Others","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Aadhaar/PAN No. (Optional)","options":[],"required":false,"pdf_field":""},{"help":"PEP means Politically Exposed Person","type":"choice","label":"If PEP* : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nominee(Relationship with Insured):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City of Residence :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation : Self employed Service","options":["Self employed","Service"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Do you have ABHA No. Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If Yes, please provide ABHA Number (Optional)","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Is any of the member proposed to be insured suffering from any illness or disease? If yes, Please provide details with Description below : Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide disease details if applicable","type":"text","label":"Disease(s) : E.g. Cancer/ Tumor, Coronary Artery Heart disease, Insulin Dependent Diabetes, Paralysis/ Stroke, Congenital Disease, HIV/ AIDS/ STD, Liver Disease, Kidney Disease, Thalassemia Major, Other (Please Specify)","options":[],"required":false,"pdf_field":""},{"help":"Provide month and year","type":"text","label":"Month & Year when such Pre-existing Disease was first detected MMYY","options":[],"required":false,"pdf_field":""},{"help":"Attach separate sheet if yes","type":"choice","label":"Has anyone been diagnosed / hospitalized or under any treatment for any illness / injury in the past ? If yes, please specify details on a separate sheet Y N","options":["Y","N"],"required":false,"pdf_field":""},{"help":"Provide claim details if yes","type":"choice","label":"Have you ever claimed under any travel policy? If yes, please give details under the section claimed. Y N","options":["Y","N"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Full name of nominee","type":"text","label":"Nominee Name","options":[],"required":true,"pdf_field":""},{"help":"Date format DD/MM/YYYY","type":"date","label":"Date of Birth (DD/MM/YYYY)","options":[],"required":true,"pdf_field":""},{"help":"Age in years","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":"Enter percentage share","type":"number","label":"Specify the percentage (%) of the claim amount payable to each nominee in the event of the policyholder's death. The total percentage of contribution across all the nominee must not exceed 100%","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":"","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":"Provide appointee details if nominee is minor","type":"text","label":"Appointee Details (Only where the Nominee age is less than 18 years)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name","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":""},{"help":"","type":"text","label":"Relationship with Nominee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"help":"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":"Attach cancelled cheque copy","type":"attachment","label":"Please submit copy of cancelled cheque along with Proposal Form","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signature","fields":[{"help":"Date of signing","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place :","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":"Premium Payment Information","fields":[{"help":"Select payment mode","type":"choice","label":"Payment By Cash / Cheque / Demand Draft / Card (Strike out whichever is not applicable) :","options":["Cash","Cheque","Demand Draft","Card"],"required":true,"pdf_field":""},{"help":"Provide cheque/DD number or authorization ID","type":"text","label":"Cheque / Demand Draft No. / Authorization ID :","options":[],"required":false,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Payment Amount (₹) :","options":[],"required":true,"pdf_field":""},{"help":"Premium payable","type":"amount","label":"Premium Amount (₹):","options":[],"required":true,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Bank name if applicable","type":"text","label":"Bank Name :","options":[],"required":false,"pdf_field":""},{"help":"Select source of funds","type":"choice","label":"Sources of Funds :","options":["Salary","Business","Others (if others, please specify)"],"required":true,"pdf_field":""},{"help":"Specify other source","type":"text","label":"If others, please specify :","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration for Agents","fields":[{"help":"Agent declaration text","type":"text","label":"I (Full Name) in my capacity as an Insurance Advisor/Specified Person of the Corporate Agent/ Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form...","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 declaration","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Signature :","options":[],"required":true,"pdf_field":""},{"help":"Agent name","type":"text","label":"SP Name :","options":[],"required":true,"pdf_field":""},{"help":"Agent code","type":"text","label":"SP Code :","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Addendum - Vernacular Declaration","fields":[{"help":"Declaration for proposer unable to read/write or with disability","type":"text","label":"I son/daughter of resident of declare that I have read out and fully explained the contents of the Proposal Form and all other accompanying documents in, language to the Proposer...","options":[],"required":true,"pdf_field":""},{"help":"Date of declaration","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Declarant 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":""}],"filled_by":"declarant"},{"title":"Optional Benefits and Packages","fields":[{"help":"","type":"yes-no","label":"I. Loss of Laptop/ Tabs/ Hand Baggage/ Personal Belongings Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit - I : Life Threatening Condition for PED : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit - 2 : Medical Expenses due to Accident only : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit - 3 : Option of Waiver of Deductible : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit - 4 : Adventure Sports Cover : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit - 5 : Refund of Visa fee (if visa Rejected) : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit - 6 : Option of Waiver of Sub-limit : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -7 : Option of Co-payment : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -8 : Anyone Illness/Injury Cover : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -9 : Coverage restricted to Specific Geography : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -10 : Medical Evacuation : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -12: Modification of Sub-limit Option : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -13 : Flight Cancellation : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -14: Luggage Tracking Service : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -15: Lounge Access in case of Flight Delay : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -16: Dental Treatment Plus : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -17: Unlimited E-Consultations : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -18: Loss of Electronic Equipment : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -19: Hotel Extension due to Contingency : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Optional Benefit -20: Card - Fraudulent Utilization : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -21: Damage to Baggage during Transit : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -22 : Physiotherapy Treatment : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -23 : Chiropractic Treatment : Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify if yes","type":"yes-no","label":"Optional Benefit -24 : Out-Patient Treatment Modification: Yes No (If yes, please specify)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Explore Travel Insurance Product","attachments":["Copy of cancelled cheque along with Proposal Form"],"declarations":["The information given is true and complete to the best of knowledge and forms basis of the insurance policy.","The policy will come into force only after full payment of premium.","Notify in writing any change in occupation or health after proposal submission but before risk acceptance.","Consent to company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","Consent to company sharing proposal and medical information with government and regulatory authorities including ABHA.","Agent declares having explained the proposal form contents and consequences of untrue statements or non-disclosure.","Vernacular declaration confirms contents were explained in a language understood by the proposer."],"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/2683-explore-proposal-form"}