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| NATIONAL INSURANCE COMPANY LIMITED |
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| Regd. Office : 3, Middleton Street, Post Box – 9229, Kolkata – 700 071. |
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| PROPOSAL FORM |
| 1) Name of the Proposer:_____________________________________________ |
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| Postal address and Telephone No._________________________________________ |
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| 2) Name and address of the educational institution where the student is pursuing his/her study: |
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| 3) Name and Address of Medical Practitioner / Family Doctor of the student: _______________________________________ |
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| 4) Sum Insured opted for hospitalisation expenses cover |
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| Rs. 50,000 ( ) Rs.75,000 ( ) Rs.100,000 ( ) |
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| Rs.125,000 ( ) Rs.150,000 ( ) Rs.175,000 ( ) Rs.200,000 ( ) |
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| 5) Details of the persons to be covered : |
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| Sl.no. |
Details |
Student |
Gurdian |
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Name |
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| 2. |
Date Of Birth |
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| 3. |
Discipline and Class of study |
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| 4. |
Sex |
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| 5. |
Relationship with
proposer |
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| 6. |
Existing ailments /diseases, if any. |
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| 7. |
Illness / Injury
sustained in past – give details. |
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| 8. |
Existing disability |
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| 6.Photographs of the student ( Stamp size – 2 each) |
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| 7. After claim free year whether you opt for Cumulative Bonus or for discount in renewal premium: |
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| 8) Do you have any existing Mediclaim Insurance ? : yes / no.
If yes |
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1) Name of Insurer : |
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2)Sum Insured : |
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| (In case of existing mediclaim, settlement will be as per the rules of the Insurance Company). |
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| Assignment: |
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| I ....................do hereby assign the moneys payable in the event of my death by National Insurance Company Limited to |
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| Sri/Smt...................my..............and I further declare that his/her receipt shall be sufficient discharge to the company. |
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Place:______________
Date:______________ |
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Signature of the guardian of the student |
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| Declaration |
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| I hereby declare and warrant that the above statements are true and complete. I have read the salient features of the policy and willing to accept the coverage subject to the terms, conditions and exclusions prescribed by the Insurance Company. |
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Place:_____________
Date:______________ |
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SIGNATURE OF THE PROPOSER. |
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| PROHIBITION OF REBATES |
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(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 a part of commission payable or any rebates of the premium-shown on the policy nor shall any person taking out or renewing or continuing a policy except any rebate as may be allowed in accordance with the published prospectus or tables of the insurer. |
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(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. |
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