{"id":363,"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/super-mediclaim---proposal-form.pdf","sha256":"fd75ccd9e84f26e765d65471f301c5fba117b0ddb1a21c2ea6d6985fb3f1c91c","pages":8,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer to apply for a Super Mediclaim health insurance policy with Care Health Insurance Limited. The proposer fills it out with personal, nominee, insured persons, and health details.","notes":["Fill the form in CAPITAL LETTERS only.","Use additional information section if space is insufficient.","Attach all required documents as part of the proposal form.","Premium payment modes other than single payment are only available for policy tenure of 2 or 3 years.","If paying premium by cash, do so 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.","If applying for portability, fill separate Portability Form.","Total nominee percentage must not exceed 100%.","If proposer is a person with disability and has appointed an authorized representative, that representative must sign where applicable.","The company may reject proposal and refund premium (less medical test costs) if form is incomplete or discrepancies found.","Key exclusions include diseases contracted in first 90 days, certain wait periods, pre-existing diseases, permanent exclusions like self-inflicted injury, pregnancy-related treatments, congenital diseases, and treatment in hospitals on negative list."],"title":"Proposal Form","submit":{"to":"Care Health Insurance Limited","how":"submit at nearest branch or authorized bank branch with computerized receipt","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":"Enter full correspondence address","type":"text","label":"Correspondence Address :","options":[],"required":true,"pdf_field":""},{"help":"Tick if permanent address is same as correspondence address","type":"checkbox","label":"Permanent Address : If same as above, please tick here","options":[],"required":false,"pdf_field":""},{"help":"Alternate phone number","type":"phone","label":"Alternate No. :","options":[],"required":false,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Telephone :","options":[],"required":false,"pdf_field":""},{"help":"Registered mobile number for WhatsApp notifications","type":"phone","label":"Mobile* :","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":"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 : 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":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark :","options":[],"required":false,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN Number :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality :","options":[],"required":true,"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":"Mother’s Name :","options":[],"required":false,"pdf_field":""},{"help":"Central KYC Registry number","type":"text","label":"CKYC:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Details","fields":[{"help":"Name of the insurance plan","type":"text","label":"Plan Opted :","options":[],"required":true,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum Insured (in Rs.) :","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Tenure : 1 Year 2 Year 3 Year","options":["1 Year","2 Year","3 Year"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Cover Type : Individual","options":["Individual"],"required":true,"pdf_field":""},{"help":"Monthly/Quarterly only for 2 or 3 year tenure","type":"choice","label":"Premium Payment Mode: Single Monthly Quarterly","options":["Single","Monthly","Quarterly"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 2 - Co-payment Option : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, fill separate Portability Form","type":"choice","label":"Are you applying for portability? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 7 - Air Ambulance Cover : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Deductible amount for Air Ambulance Cover","type":"amount","label":"If Yes, then please mention Deductible (in Rs.) :","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 1 - Deductible Option : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 3 - Unlimited Automatic Recharge : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 4 - International Second Opinion : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 6 - Additional Sum Insured for Accidental Hospitalization : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 8 - Reduction on PED Wait Period : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Optional Cover 5 - Room Rent Modification : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If you do not have an eIA, 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","Karvy Insurance Repository Limited","CIRL-Central Insurance Repository Limited (CDSL)"],"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":"Nominee Details","fields":[{"help":"Name of nominee","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Total 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":"Includes 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 Proposed to be Insured Including Proposer","fields":[{"help":"Full name of insured person","type":"text","label":"Name : Mr./Ms./Mrs.","options":[],"required":true,"pdf_field":""},{"help":"Name of nominee for this insured","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":"Politically Exposed Person status","type":"choice","label":"If PEP* : Yes No","options":["Yes","No"],"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","type":"date","label":"Date of Birth","options":[],"required":true,"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":"","type":"text","label":"If Yes, please provide ABHA Number (Optional)","options":[],"required":false,"pdf_field":""},{"help":"Attach disability certificate if yes","type":"choice","label":"Do you fall under the category of Differently Abled Persons? : Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"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":"Details of Previous or Existing Health Insurance","fields":[{"help":"","type":"choice","label":"Is any of the person(s) proposed for insurance covered under any other health insurance policy with the Care Health Insurance? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Has any of your proposal(s) for Health insurance been declined, cancelled, charged a higher premium or issued with special condition(s)? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide details on a separate sheet","type":"choice","label":"Have any of the person(s) to be insured ever filed a claim with their current/previous insurer? Yes No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Attending Physician's Details","fields":[{"help":"","type":"text","label":"Name of Family Physician","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Information","fields":[{"help":"Use this section to provide extra details","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":"","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Amount paid","type":"amount","label":"Payment Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"Premium amount","type":"amount","label":"Premium Amount (`)","options":[],"required":true,"pdf_field":""},{"help":"If payment by cheque or draft","type":"text","label":"Cheque/ Demand Draft No./ Authorization ID","options":[],"required":false,"pdf_field":""},{"help":"Date of payment","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Installment amount if applicable","type":"amount","label":"Installment Amount (INR, in case Premium Payment Mode is Monthly/Quarterly)","options":[],"required":false,"pdf_field":""},{"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":""}],"filled_by":"proposer"},{"title":"NEFT Details (For Claims & Refund Purposes)","fields":[{"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":""},{"help":"","type":"text","label":"Account Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"IFSC Code","options":[],"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":"Agent Declaration","fields":[{"help":"Date of signing","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":""},{"help":"Agent license number","type":"text","label":"License No. (Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Acknowledgement for Proposal","fields":[{"help":"Proposal number assigned by insurer","type":"text","label":"Proposal No.","options":[],"required":false,"pdf_field":""},{"help":"Name of company representative","type":"text","label":"Name of the Representative","options":[],"required":false,"pdf_field":""},{"help":"Signature of company representative","type":"signature","label":"Signature of the Representative","options":[],"required":false,"pdf_field":""}],"filled_by":""}],"deadlines":[],"applies_to":"Super Mediclaim health insurance policy proposals","attachments":["Proof of Identity (POI) - tick applicable document","Proof of Address (POA) - tick applicable document","Medical documents such as discharge summary, investigation reports, follow up records, angiography report, latest ECHO, ECG, stress test","Disability certificate if proposer or insured is differently abled"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","The company may share proposal and medical information with government or regulatory authorities including via ABHA.","The agent declares having explained the proposal form contents and consequences of untrue statements or non-disclosure.","The proposer authorizes direct credit of payouts/refunds to the provided bank account."],"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/363-proposal-form"}