{"id":2686,"title":"Assure (Critical Illness Insurance Product) - 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/assure-(critical-illness-insurance-product)---proposal-form.pdf","sha256":"87cd33ee0e0aa30642a5997889066e9ff63005d1781879d2c611dc4a29a6f846","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities proposing to purchase the Assure Critical Illness Insurance policy from Care Health Insurance Limited. The proposer fills this form to provide personal, nominee, policy, medical, and previous insurance details for underwriting and policy issuance.","notes":["Fill the form in CAPITAL LETTERS only.","The company is not obliged to accept any proposal or issue a policy merely by submission of this form or payment.","Policy liability commences only after acceptance, underwriting, and receipt of premium.","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.","Use original documents for proof of identity and address.","If paying premium by cash, do so only at nearest branch or authorized bank branch and obtain computerized receipt.","Claims without computerized receipt for cash payments will not be admitted.","For ECS payment, submit standing instruction form available at branches.","If applying for portability, fill separate Portability Form.","If proposer is person with disability and has authorized representative, signature of authorized representative is required.","Total percentage of claim amount payable to nominees must not exceed 100%.","Attach disability certificate if differently abled.","Provide medical documents wherever applicable.","The form includes statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938."],"title":"Assure (Critical Illness Insurance Product) - Proposal Form","submit":{"to":"Care Health Insurance Limited","how":"submit at nearest branch or authorized bank branch; also via intermediary or point of sales person","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":"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 applicable, enter key person name","type":"text","label":"Key Person Name : (Mr./Ms./Mrs.) (First Name) (Middle Name) (Last Name)","options":[],"required":false,"pdf_field":""},{"help":"Enter full correspondence 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":"","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 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":"If same as correspondence address, tick the box","type":"text","label":"Permanent Address :","options":[],"required":true,"pdf_field":""},{"help":"Tick if permanent address is same as correspondence address","type":"checkbox","label":"If same as above, please tick here","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Locality :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City :","options":[],"required":false,"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 Code :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"","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":"DD/MM/YYYY format","type":"date","label":"Date of Birth / Incorporation (in case Proposer is an entity) :","options":[],"required":true,"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":"Permanent Account Number","type":"text","label":"PAN Number :","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":""}],"filled_by":"proposer"},{"title":"Insured Person Details","fields":[{"help":"Full name in capital letters","type":"text","label":"Name : Mr./Ms./Mrs.","options":[],"required":true,"pdf_field":""},{"help":"In cms","type":"number","label":"Height","options":[],"required":false,"pdf_field":""},{"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":"In lakhs","type":"amount","label":"Annual Income","options":[],"required":false,"pdf_field":""},{"help":"In kgs","type":"number","label":"Weight","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Aadhaar/PAN No. (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Name of nominee","type":"text","label":"Nominee","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City of Residence","options":[],"required":false,"pdf_field":""},{"help":"PEP means Politically Exposed Person","type":"yes-no","label":"If PEP*","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, enclose disability certificate with percentage","type":"yes-no","label":"Do you fall under the category of Differently Abled Persons ?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter percentage of disability","type":"number","label":"Specify the percentage of impairment.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Please enter the Unique Disability ID (UDID) Number.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Proposed Policy Period Start Date","options":[],"required":true,"pdf_field":""},{"help":"Name of the plan","type":"text","label":"Plan","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured (in Rs.)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Tenure","options":["1 Year","2 Year","3 Year"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Everyday Care Add-on Benefit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"HIV Cover Add-on Benefit","options":["Yes","No"],"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":""},{"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: Name of Insurance Repository","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"eIA No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name as appearing in eIA","options":[],"required":false,"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":"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":false,"pdf_field":""},{"help":"","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":"","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":"Enter 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 Previous or Existing Health Insurance","fields":[{"help":"","type":"yes-no","label":"Have any of the person(s) to be insured ever filed a claim with their current/ previous insurer? If Yes, please provide details on a separate sheet","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 Care Health Insurance?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details including since when (DD/MM/YYYY)","type":"table","label":"Details of previous or existing health insurance for each insured person","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Premium Payment Information","fields":[{"help":"","type":"choice","label":"Payment By: Cash / Cheque / Demand Draft / Card / ECS (NACH) / Reward Points / Wallet / Any other mode (Strike out whichever is not applicable)","options":["Cash","Cheque","Demand Draft","Card","ECS (NACH)","Reward Points","Wallet","Other"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Premium payment mode: Single / Monthly / Quarterly / Half-yearly (Tick whichever is applicable)","options":["Single","Monthly","Quarterly","Half-yearly"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Cheque / Demand Draft No. / Authorization ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Payment Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"","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":"","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Declaration","fields":[{"help":"","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":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"SP Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"SP Code","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Vernacular Declaration","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"declarant"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"help":"","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"","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":"Only if proposer is person with disability and has authorized representative","type":"signature","label":"Signature of the Declarant/Authorized Representative","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Proposal for Assure Critical Illness Insurance Product","attachments":["Proof of Identity (POI) - PAN, Aadhaar, Passport, Driving License, Voter ID Card, Letter from recognized public authority","Proof of Address (POA) - 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 recognized public authority","Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test","Copy of cancelled cheque for NEFT details"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The proposer consents to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","The proposer authorizes the company to share proposal and medical information with government and regulatory authorities including ABHA.","The agent declares that the proposal form contents have been explained to the proposer and that untrue statements may lead to policy being void.","The proposer authorizes Care Health Insurance Limited to directly credit payouts/refunds to the provided bank account."],"dropped_labels":8},"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/2686-assure-critical-illness-insurance-product-proposal-form"}