Proposal Form, Mediclaim Proposal Form, Specimen Proposal Form, Proposal Forms, Proposal Form

Signature of the Proposer

STATUTORY WARNING

PROHIBITION OF REBATES
(Under Section 41 of Insurance Act 1938)

1. No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer. 
    
   
2. Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.

MEDICAL DECLARATION CUM STATEMENT FOR PERSONS AGED 70+
Medical Details (to be completed by the Proposer) 

1. Are you in good health and free from physical and mental disease or infirmity?
2. Have you ever suffered from any illness or disease up to the date of making this proposal?
3. Do you have any physical defect or deformity?
4. Have you ever been admitted to any hospital/nursing home /clinic for treatment or observation?
5. Have you suffered from any illness/disease or had an accident in the 12 months preceding the first day of insurance?
6. If the answer is "Yes" to any of the above, please give details:
• Nature of illness/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 no.
7. Please give details of any positive existence of any ailment, sickness or injury which may require medical attention whilst on tou