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Individual Health Insurance Proposal Form

Individual Health Insurance (Health Protect)

Step 1 of 5

20%

Name*
Prefix First Middle Last
Nepal Address*
Municipality/ VDC District State Ward No. Street Name/ Tole
India Address
Locality City Pin Code State
Contact Detail
Landline (R)*
Landline (O)
Mobile Number*
Alternate Number
Email*
Date of Birth*
Gender*
- Male
- Female
- Others
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Mother's Name*
First Middle Last
Nationality*
- Nepal
- Other than Nepal

Nominee Details
Name*
First Last
Date of Birth*
Relationship with Proposer*
Is the age of Nominee 18 years or less?*
- Yes
- No
Appointee Name*
First Last
Date of Birth*
Relationship with Minor*
In event of the death of the Proposer, any payment due under the Policy shall become payable to the Nominee proposed in this Proposal Form. The receipt of the proceeds by the Nominee would be sufficient discharge of the Company. The Nominee for all the other person(s) proposed to be insured shall be the Proposer himself.
Policy Details
Sum Insured (in Rs.)*
Tenure*
- 1 Year
- 2 Years
- 3 Years
Coverage Type*
- Individual
- Floater

Details Of The Proposed To Be Insured Including Proposer
Number of proposed to be insured including proposer*
Please enter a number from 1 to 5.
Insured 1:
Name*
Prefix First Middle Last
Height*
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Date of Birth*
Annual Income*
Weight*
Gender*
- Male
- Female
- Others
KYC Name No. (optional)
Nominee (Relationship with Insured)*
Realtionship with Proposer*
City of Residence*
City
Occupation*
Insured Person PAN No.
Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous material, working at heights/underground/construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or adventure sports or armed forces?*
- Yes
- No
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations or important political party officials.*
- Yes
- No
Insured 2:
Name*
Prefix First Middle Last
Height*
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Date of Birth*
Annual Income*
Weight*
Gender*
- Male
- Female
- Others
KYC Name No. (optional)
Nominee (Relationship with Insured)
Relationship with Proposer*
Address*
City
Occupation*
Insured Person PAN No.
Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous material, working at heights/underground/construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or adventure sports or armed forces?*
- Yes
- No
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations or important political party officials.*
- Yes
- No
Insured 3:
Name*
Prefix First Middle Last
Height*
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Date of Birth*
Annual Income*
Weight*
Gender*
- Male
- Female
- Others
KYC Name No. (optional)
Nominee (Relationship with Insured)*
Relationship with Proposer*
City of Residence*
City Country
Occupation*
Insured Person PAN No.*
Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous material, working at heights/underground/construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or adventure sports or armed forces?*
- Yes
- No
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations or important political party officials.*
- Yes
- No
Insured 4:
Name*
Prefix First Middle Last
Height*
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Date of Birth*
Annual Income*
Weight*
Gender*
- Male
- Female
- Others
KYC Name No. (optional)
Nominee (Relationship with Insured)*
Relationship with Proposer*
City of Residence*
Occupation*
Insured Person PAN No.
Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous material, working at heights/underground/construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or adventure sports or armed forces?*
- Yes
- No
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations or important political party officials.*
- Yes
- No
Insured 5:
Name*
Prefix First Middle Last
Marital Status*
- Single
- Married
- Divorced
- Widow(er)
- Seperated
Height*
Date of Birth*
Annual Income*
Weight*
Gender*
- Male
- Female
- Others
KYC Name No. (Optional)
Nominee (Relationship With Insured)*
Realtionship with Proposer*
City of Residence*
City
Occupation*
Insured Personal PAN No.
Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous material, working at heights/underground/construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or adventure sports or armed forces?*
- Yes
- No
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations or important political party officials.*
- Yes
- No

Medical/ Lifestyle Related Information
Has any proposed insured currently or in past Diagnosed/Suffered/Treated/Taken Medication for any of the following conditions: If yes, please provide details in the additional information section below:
1. Cancer, tumor, polyp or cyst
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
2. Any heart disease or disorder, chest pain or discomfort, irregular heartbeats, palpitations or heart murmur
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
3. Hypertension / High Blood Pressure(BP)/ High Cholesterol/Any other Lipid disorders
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
4. Asthma / Tuberculosis (TB) / COPD/ Pleural effusion / Bronchitis / Emphysema or any other disease of Lungs, Pleura, and airway or Respiratory disease?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
5. Thyroid disease/ Cushing's disease/ Parathyroid Disease/ Addison's disease / Pituitary tumor/ disease or any other sorder of the Endocrine system?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
6. Diabetes Mellitus / High Blood Sugar / Diabetes on Insulin or medication
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
7. Motor Neuron Disease/ Muscular dystrophies/ Myasthenia Gravis or any other disease of Neuromuscular system (muscles and/or nervous system)
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
8. Stroke/ Paralysis/ Transient Ischemic Attack/ Multiple Sclerosis/ Epilepsy/ Mental-Psychiatric illness/ Parkinsonism/ Alzheimer's/ Depression / Dementia or any other disease of Brain and Nervous System?
Insured 1*
- Yes
- No
Since
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
9. Cirrhosis / Hepatitis / Wilson's disease / Pancreatitis / Liver disease / Crohn's disease / Ulcerative Colitis /Piles or any other disease of Mouth, Esophagus, Liver, Gall bladder, Stomach or Intestines or any other part of Digestive System?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
10. Kidney Stones/ Renal Failure/ Dialysis/ Chronic Kidney Disease/ Prostate Disease or any other disease of Kidney, Urinary Tract or reproductive organs?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
11. HIV/SLE/ Arthritis/ Scleroderma / Psoriasis/ bleeding or clotting disorders or any other diseases of Blood, Bone marrow/ Immunity, or Skin.
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
12. Disease or disorder of eye, ear, nose or throat (except any sight related problems corrected by prescription lenses)?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
Drink Hard Liquor
Insured 1
- Yes
- No
No. of Pegs in 30 ml per week*
Insured 2
- Yes
- No
No. of Pegs in 30 ml per week*
Insured 3
- Yes
- No
No. of Pegs in 30 ml per week*
Insured 4
- Yes
- No
No. of Pegs in 30 ml per week*
Insured 5
- Yes
- No
No. of Pegs in 30 ml per week*
Drink Beer
Insured 1*
- Yes
- No
Bottles/ml per week*
Insured 2*
- Yes
- No
Bottles/ml per week*
Insured 3*
- Yes
- No
Bottles/ml per week*
Insured 4*
- Yes
- No
Bottles/ml per week*
Insured 5*
- Yes
- No
Bottles/ml per week*
Drink Wine
Insured 1*
- Yes
- No
Glasses/ml per week*
Insured 2*
- Yes
- No
Glasses/ml per week*
Insured 3*
- Yes
- No
Glasses/ml per week*
Insured 4*
- Yes
- No
Glasses/ml per week*
Insured 5*
- Yes
- No
Glasses/ml per week*
Smoke
Insured 1*
- Yes
- No
Number of sticks per day*
Insured 2*
- Yes
- No
Number of sticks per day*
Insured 3*
- Yes
- No
Number of sticks per day*
Insured 4*
- Yes
- No
Number of sticks per day*
Insured 5*
- Yes
- No
Number of sticks per day*
Gutka/Pan Masala/Chewing Tobacco
Insured 1*
- Yes
- No
Sachets/ Grams per day*
Insured 2*
- Yes
- No
Sachets/ Grams per day*
Insured 3*
- Yes
- No
Sachets/ Grams per day*
Insured 4*
- Yes
- No
Sachets/ Grams per day*
Insured 5*
- Yes
- No
Sachets/ Grams per day*
Any other disease / health adversity / injury/ condition / treatment not mentioned above?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
15. Has any of the Proposed to be Insured been hospitalized /recommended to take investigations/medication or has been under any prolonged treatment/ undergone surgery for any illness/injury other than for childbirth/minor injuries?
Insured 1*
- Yes
- No
Since*
Insured 2*
- Yes
- No
Since*
Insured 3*
- Yes
- No
Since*
Insured 4*
- Yes
- No
Since*
Insured 5*
- Yes
- No
Since*
Note: The Company shall reject Your proposal and refund the premium amount (after deducting the cost of medical tests, if any) in case of incompleteness or any discrepancy highlighted or any other reason.

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 Exisitng Disease Which Is Not Mentioned In The Above List)
Attending Physician's Detail
Name of Family Physician*
First Last
Contact Number*
Details Of Previous Or Existing Health Insurance (Optional)
Please fill the following details with respect to health insurance proposals / policies with the Company or any other insurance companies.
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
Insured 1
- Yes
- No
Insured 2
- Yes
- No
Insured 3
- Yes
- No
Insured 4
- Yes
- No
Insured 5
- Yes
- No
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
Insured 1
- Yes
- No
Insured 2
- Yes
- No
Insured 3
- Yes
- No
Insured 4
- Yes
- No
Insured 5
- Yes
- No
Has any of your proposal(s) for Health insurance been declined, cancelled, charged a higher premium or issued with special condition(s)?
Insured 1
- Yes
- No
Insured 2
- Yes
- No
Insured 3
- Yes
- No
Insured 4
- Yes
- No
Insured 5
- Yes
- No
*
I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and / or particulars given by me are true and complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of these other persons.
*
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy will come into force only after full payment of the premium chargeable.
*
I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured / proposer after the proposal has been submitted but before communication of the risk acceptance by the company.
*
I declare that I consent to the company seeking medical information from any doctor or hospital who / which at any time has attended on the person to be insured/ proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured / proposer and seeking information from any Insurer to whom an application for insurance on the person to be insured / proposer has been made for the purpose of underwriting the proposal and / or claim settlement.
*
I authorize the company to share information pertaining to my proposal including the medical records of the Insured/ Proposer for the sole purpose of underwriting the proposal and / or claims settlement and with any Governmental and / or Regulatory authority.

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Individual Health Insurance (Health Protect)

Step 1 of 5

Contact Detail

Nominee Details

Policy Details

Details Of The Proposed To Be Insured Including Proposer

Insured 1:

Insured 2:

Insured 3:

Insured 4:

Insured 5:

Medical/ Lifestyle Related Information

Has any proposed insured currently or in past Diagnosed/Suffered/Treated/Taken Medication for any of the following conditions: If yes, please provide details in the additional information section below:

1. Cancer, tumor, polyp or cyst

2. Any heart disease or disorder, chest pain or discomfort, irregular heartbeats, palpitations or heart murmur

3. Hypertension / High Blood Pressure(BP)/ High Cholesterol/Any other Lipid disorders

4. Asthma / Tuberculosis (TB) / COPD/ Pleural effusion / Bronchitis / Emphysema or any other disease of Lungs, Pleura, and airway or Respiratory disease?

5. Thyroid disease/ Cushing's disease/ Parathyroid Disease/ Addison's disease / Pituitary tumor/ disease or any other sorder of the Endocrine system?

6. Diabetes Mellitus / High Blood Sugar / Diabetes on Insulin or medication

7. Motor Neuron Disease/ Muscular dystrophies/ Myasthenia Gravis or any other disease of Neuromuscular system (muscles and/or nervous system)

8. Stroke/ Paralysis/ Transient Ischemic Attack/ Multiple Sclerosis/ Epilepsy/ Mental-Psychiatric illness/ Parkinsonism/ Alzheimer's/ Depression / Dementia or any other disease of Brain and Nervous System?

9. Cirrhosis / Hepatitis / Wilson's disease / Pancreatitis / Liver disease / Crohn's disease / Ulcerative Colitis /Piles or any other disease of Mouth, Esophagus, Liver, Gall bladder, Stomach or Intestines or any other part of Digestive System?

10. Kidney Stones/ Renal Failure/ Dialysis/ Chronic Kidney Disease/ Prostate Disease or any other disease of Kidney, Urinary Tract or reproductive organs?

11. HIV/SLE/ Arthritis/ Scleroderma / Psoriasis/ bleeding or clotting disorders or any other diseases of Blood, Bone marrow/ Immunity, or Skin.

12. Disease or disorder of eye, ear, nose or throat (except any sight related problems corrected by prescription lenses)?

Drink Hard Liquor

Drink Beer

Drink Wine

Smoke

Gutka/Pan Masala/Chewing Tobacco

Any other disease / health adversity / injury/ condition / treatment not mentioned above?

15. Has any of the Proposed to be Insured been hospitalized /recommended to take investigations/medication or has been under any prolonged treatment/ undergone surgery for any illness/injury other than for childbirth/minor injuries?

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 Exisitng Disease Which Is Not Mentioned In The Above List)

Attending Physician's Detail

Details Of Previous Or Existing Health Insurance (Optional)

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

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

Has any of your proposal(s) for Health insurance been declined, cancelled, charged a higher premium or issued with special condition(s)?