{"id":898,"title":"Overseas Mediclaim Insurance Policy Proposal Form","purpose":"proposal","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/OMP%20E%26S%20-%20Proposal%20Form.pdf","sha256":"082bff97670c21826e3b8b2b92c7746f0e7f6a60ccb769a8cec803fe1ae2e5b9","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Overseas Mediclaim Insurance Policy for Employment & Studies. The proposer fills it to provide personal, study/employment, and medical details for underwriting the insurance.","notes":["Fill the form in BLOCK LETTERS.","Paste one stamp sized photograph and sign beside it (guardian or proposer may sign if minor).","For students under 18 and/or residing with parents, one parent must also sign to confirm accuracy.","The proposal form must be signed by the proposer, not by a representative.","Doctor's section to be completed by an M.D. only.","Use original medical reports as required.","Section 41 of Insurance Act, 1938 prohibits rebates as inducement for insurance."],"title":"Overseas Mediclaim Insurance Policy Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer details","fields":[{"help":"Write full name exactly as in passport","type":"text","label":"Name of the Proposer (As in passport)","options":[],"required":true,"pdf_field":""},{"help":"Full residential address in India","type":"text","label":"Home Address in India","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal Index Number","type":"number","label":"PIN","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E -Mail","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of birth (as in passport)","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender (M/F)","options":["M","F"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Blood group","options":[],"required":false,"pdf_field":""},{"help":"Height in centimeters","type":"number","label":"Height (cms)","options":[],"required":false,"pdf_field":""},{"help":"Weight in kilograms","type":"number","label":"Weight","options":[],"required":false,"pdf_field":""},{"help":"Passport number","type":"text","label":"Passport No.","options":[],"required":true,"pdf_field":""},{"help":"Passport expiry date DD/MM/YYYY","type":"date","label":"Date of expiry","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Passport issuing office","options":[],"required":false,"pdf_field":""},{"help":"Start date of insurance coverage","type":"date","label":"Period of Insurance (from)","options":[],"required":true,"pdf_field":""},{"help":"Total number of days insured","type":"number","label":"No. of days","options":[],"required":true,"pdf_field":""},{"help":"Name of country, number of days of stay and type of visa held","type":"text","label":"Country of study","options":[],"required":true,"pdf_field":""},{"help":"Select one plan","type":"choice","label":"Type of plan","options":["Plan C","Plan D","Plan D1"],"required":true,"pdf_field":""},{"help":"Sum Insured in US dollars","type":"amount","label":"SI opted for","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the family medical practitioner","options":[],"required":false,"pdf_field":""},{"help":"Address of family medical practitioner","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Phone number of family medical practitioner","type":"phone","label":"Contact no.","options":[],"required":false,"pdf_field":""},{"help":"Name as per bank account","type":"text","label":"Name in Bank Account","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Account number, MICR code, IFSC code","type":"text","label":"A/C no./MICR/IFSC","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Photograph","fields":[{"help":"Paste one stamp sized photograph and sign beside it (guardian or proposer may sign if minor)","type":"photo","label":"Photograph","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Study/ Employment details","fields":[{"help":"","type":"text","label":"Country of Study/ posting","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address in country of study/ posting","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of school/ college/ firm (abroad)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Brief details of nature of studies / research/ employment and activities to be undertaken","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name and address of Indian Sponsor/ firm","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with sponsor","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Course commencement Date/ Joining date","options":[],"required":true,"pdf_field":""},{"help":"Number of months","type":"number","label":"Total period of months that you are intending to study in/ work at the country of study/ posting","options":[],"required":true,"pdf_field":""},{"help":"Month and year of end","type":"date","label":"To (MM/YYYY)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical history of proposer or insured person","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Are you in good health and free from physical and mental disease or infirmity","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you ever suffered from any illness or disease up to the date of making this proposal","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Do you have any physical defect or deformity?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you ever been admitted to any hospital/ nursing home/clinic for treatment or observation","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you suffered from any illness/disease of had an accident in the 12 months preceding the first day of insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide full details if any answer above is Yes","type":"text","label":"If answer is ‘yes’ to any of the foregoing questions please give full details as under: Nature of illness/ medical disease/injury & treatment received, Date on which first treatment taken, First treatment completed/ is continuing, Name of attending Medical practitioner / surgeon with his address and telephone","options":[],"required":false,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Have you any intention of engaging in professional sports?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if intending professional sports","type":"text","label":"If ‘Yes’, give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Please give details of any knowledge of any positive existence of any ailment, sickness or injury which may require medical attention whilst on tour abroad.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical reports submission","fields":[{"help":"Indicate if ECG report is submitted","type":"yes-no","label":"ECG","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if fasting blood sugar report is submitted","type":"yes-no","label":"Fasting blood sugar","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if urine strip test report is submitted","type":"yes-no","label":"Urine strip test","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if any other medical test report is submitted","type":"yes-no","label":"Any other test","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Certificate from proposer if form filled by representative","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":false,"pdf_field":""},{"help":"Print name in block letters","type":"text","label":"Name of the Proposer (in BLOCK LETTERS)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Parent confirmation for students under 18","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Date of signing DD/MM/YYYY","type":"date","label":"Date","options":[],"required":false,"pdf_field":""}],"filled_by":"parent"},{"title":"Annexure I - To be completed by the Doctor","fields":[{"help":"Doctor to describe past medical history","type":"text","label":"Any past history of disease, operation, accidents, investigations etc.","options":[],"required":true,"pdf_field":""},{"help":"Doctor to describe general examination findings","type":"text","label":"General Examination","options":[],"required":true,"pdf_field":""},{"help":"Doctor to describe systemic examination findings","type":"text","label":"Systemic Examination","options":[],"required":true,"pdf_field":""},{"help":"Doctor to answer Yes or No","type":"yes-no","label":"Does the proposer now or did he/she in the past, require medication for this abnormality?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Doctor to describe treatment","type":"text","label":"Please describe any treatment taken by Proposer in the past or being taken at present","options":[],"required":true,"pdf_field":""},{"help":"Doctor to answer Yes or No","type":"yes-no","label":"Do you recommend Stress Test? If so please obtain the report of such test.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Doctor to answer Yes or No","type":"yes-no","label":"Does the urine Strip Test show any sugar?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Doctor to answer Yes or No","type":"yes-no","label":"Do you consider that proposer is fit to travel anywhere abroad, due account being taken of the stress of air travel adversely affecting his health/medical condition?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Doctor to sign","type":"signature","label":"Signature of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualifications","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Telephone No.","options":[],"required":true,"pdf_field":""}],"filled_by":"doctor"}],"deadlines":[],"applies_to":"Overseas Mediclaim Policy for Employment & Studies","attachments":["One stamp sized photograph","Medical reports as per Important Instruction IX (ECG, Fasting blood sugar, Urine strip test, Any other test)","Electrocardiogram report if applicable","Stress Test report if recommended"],"declarations":["I will not be traveling against the advice of a physician.","I am not on the waiting list for any medical treatment.","I will not be traveling for the purpose of obtaining medical treatment.","I have not received a terminal prognosis for a medical condition before this day.","The statements and particulars given are true and complete to the best of my knowledge.","I will notify in writing any change in occupation or health after submission but before risk acceptance.","I consent to the company seeking medical information from doctors, hospitals, past or present employers, and other insurance companies for underwriting and claim settlement.","I authorize the company to share information pertaining to my proposal including medical records with Governmental and/or Regulatory authorities."],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customer.support@nic.co.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh Contrast\nInvert\nSaturation","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"18003450330","label":"Toll-Free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"National Insurance Company Limited: Trusted Since 1906\nSkip to main content\nToll-Free 18003450330\ncustomer.support@nic.co.in\nSearch\nSkip to main content\nbhashini\nAccessibility Options\nAccessibility Options\nReset\nHigh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"033-22022100","label":"Head Office Telephone","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/","quote":"d and Head Office\nPremises No. 18-0374, Plot No. CBD-81,\nNew Town, Kolkata-700156\nCIN: U10200WB1906GOI001713\nTelephone: 033-22022100\nFacebook\ninstagram\nX (Twitter)\nyoutube\nlinkedin\nWhatsapp\nBEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS /FRAUDULENT OFFE","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"9920501906","label":"WhatsApp Us","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/contact-us","quote":"h Us For Answers And Assistance—Your Gateway To Communication With Our Team.\nCustomer Service\n1800 345 0330\nWhatsApp Us\n9920501906\nHead Office\nPremises No. 18-0374, Plot No. CBD-81, New Town,  Kolkata - 700156\nTelephone: 033-22022100\nNote: Official c","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156","label":"Grievance Redressal Postal Address","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"e: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No. 18- 0374, Plot no. CBD-81, New Town, Kolkata - 700156 Insurance Ombudsman – As per Appendix attached to Policy. | 7\n12. | Things to Remember | Implied renewability (except o","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"customer.relations@nic.co.in","label":"Grievance Redressal Officer Email","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot no. CBD-81, New Town, Kolkata – 70015","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800 345 0330","label":"Grievance Toll free","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/National%20Suryoday%20Policy%20-%20CIS.pdf","quote":"holders Protection | • Details of Grievance redressal officer: Website: https://nationalinsurance.nic.co.in/ Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Phn: (033) 25370070 Post: National Insurance Co. Ltd.,\nPremises No. 18-0374, Plot","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"url","value":"https://nationalinsurance.nic.co.in/en/grievance","label":"Grievance Website","level":null,"hours":null,"applies_to":"all","source_url":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Rajrajeshwari%20Freedom_CIS_Revised_Grp.pdf","quote":"ice\n11. | Grievances/ Complaints | In case of any grievance the insured person may contact the company through Website: https://nationalinsurance.nic.co.in/en/grievance Toll free: 1800 345 0330 E-mail: customer.relations@nic.co.in Post: CRM Dept., National Insurance Co. Ltd., Premises No","fetched_at":"2026-10-20"}],"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/national-insurance/898-overseas-mediclaim-insurance-policy-proposal-form"}