PROPOSAL FORM FOR OVERSEAS MEDICLAIM POLICY
(Business & Holiday)
(To be submitted in original with 2 copies)
(Available to persons in the age group of 6 months to 70 years)
THE OVERSEAS MEDICLAIM POLICY PROVIDES INDEMNITY FOR EXPENSES NECESSARILY INCURRED FOR IMMEDIATE TREATMENT OF ILLNESS, DISEASES ONTRACTED OR INJURY FIRST SUSTAINED (DURING THE PERIOD OF INSURANCE OF OVERSEAS TRAVEL SUBJECT TO POLICY TERMS AND CONDITIONS) AND IN ADDITION ALSO PERSONAL ACCIDENT, TOTAL LOSS OF CHECKED ENGAGE, DELAY OF CHECKED BAGGAGE, LOSS OF PASSPORT AND PERSONAL LIABILITY COVERS. (DURING THE PERIOD OF INSURANCE OF OVERSEAS TRAVEL SUBJECT TO POLICY TERMS AND CONDITIONS)
IN THE ABSENCE OF MEDICAL REPORTS AS SPECIFIED IN ITEM IIB SUM INSURED WILL STAND REDUCED TO AN EQUIVALENT AMOUNT OF US$ 10000 IN RESPECT OF MEDICAL EXPRESS INCURRED THROUGH ILLNESS OR DISEASE ONLY, SUBJECT TO EXCLUSION OF PRE-EXISTING DISEASE.
THE ATTENTION OF THE PROPOSER IS DRAWN TO ITEM II (MEDICAL HISTORY) OF THE PROPOSAL FORM ESPECIALLY IN RELATION TO PREVIOUS TREATMENT FOR ILLNESS OR DISEASES SUCH AS RENAL DISORDERS OR DISEASES. CEREBRAL OR VASCULAR STROKES, HEART AILMENTS OF ANY KIND, MALIGNANCY, TUBERCULOSIS, ENCEPHALITIS, NEUROLOGICAL DISORDERS, GALL BLADDER DISORDERS ARTHRITIS REQUIRING SURGERY AND IF ANY TREATMENT HAS BEEN RECEIVED FOR ANY OF THE ABOVE DISORDERS AT ANY TIME IN THE PAST SUCH TREATMENT MUST BE DISCLOSED TO THE POLICY ISSUING OFFICE.
NEITHER THE INSURERS NOR CLAIMS SETTLING AGENTS SHALL BE RESPONSIBLE FOR THE AVAILABILITY, QUALITY OR RESULTS OF ANY MEDICAL TREATMENT OR THE FAILURE OF THE INSURED TO OBTAIN MEDICAL TREATMENT.
THE PROPOSAL FORM SHOULD BE COMPLETED TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, AND ALL MATERIAL FACTS SHOULD BE DISCLOSED. FAILURE TO DO SO MAY NULLIFY COVER UNDER THE POLICY ISSUED.
Medical Reports are required
A) Trip is for period over 60 days and if
a) insured person if over 40 yrs of age visiting USA/Canada
b) insured is over 60 yrs of age and visiting countries other than USA/Canada
B) Proposal reveals that insured had suffered from / suffering from any illness / disease.
The proposal form should be accompanied with 1)ECG printout with report and 2) Fasting blood sugar and Urine Strip Test Report or any other medical report required by the company etc. along with the attached questionnaire II(B) to be completed and signed by the Doctor with minimum M.D. qualification conducting the test. In the absence of such medical tests and reports due to a shortage of time before travel, cover may still be granted subject to a satisfactory proposal form but the sum insured under policy, in respect of expenses incurred for the treatment of illness or disease shall be restricted to US $ 10,000 only, which shall not cover the cost of Medical treatment for pre-existing disease. In case of accident however the full sum insured benefit would be available.
I. GENERAL INFORMATION
1. NAME OF THE PROPOSER: MR./ MRS./MISS. /MASTER
(IN BLOCK LETTERS) AS STATED
IN THE PASSPORT
2. HOME ADDRESS & TELEPHONE NO. :
3. PROPOSER’S ACTUAL OCCUPATION :
4. OFFICE ADDRESS :
5. TELEPHONE NO. :
6. AGE (IN COMPLETED YEARS) :______DATE OF BIRTH _____
7. PASSPORT NO. :________________________
DATE OF EXPIRY & NAME OF PASSPORT
8. PLAN OPTED FOR : A-1 A-2 B-1 B-2 E-1 E-2 K
(Please tick relevant plan)
9. PURPOSE OF VISIT :
10. PROPOSED DATE OF DEPARTURE FROM : DAY MONTH YEAR
REPUBLIC OF INDIA i.e. FIRST DAY OF
11. INSURANCE REQUIRED FOR :
(Number of days)
N.B.:1. In case of any extension of stay abroad, requiring extension of policy period, approval of issuing office has to be obtained and appropriate premium paid before expiry of policy. Request for such extension should be supported with a declaration of good health.
2. In case of early return partial refund of premium will be permitted if the original cover is for maximum period of 60 days and unexpired period is not less than 14 days and also if no claim is lodged under the policy.
12. COUNTRIES TO BE VISITED :
(State appropriate number of days at each place)
13. NAME, REGISTRATION NO. :
ADDRESS & TELEPHONE NO
OF FAMILY PHYSICIAN
II MEDICAL HISTORY
(A) TO BE COMPLETED BY THE PROPOSER
PLEASE ANSWER THE FOLLOWING QUESTION WITH ‘YES’ OR ‘NO’ (A DASH IS NOT SUFFICIENT) AND GIVE FULL DETAILS
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 of
had an accident in the 12 months preceding the
first day of insurance _____________________
6. 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
7. a) Have you any intention of engaging in professional sports ? :
b) If so, give details:
8. 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.
I HEREBY DECLARE THAT
1. I will not be traveling against the advice of a physician
2. I am not on the waiting list for any medical treatment
3. I will not be traveling for the purpose of obtaining medical treatment
4. I have not received a terminal prognosis for a medical condition before this day.
I....................................................do hereby assign the monies payable under the policy in the event of my death to my.............................................(relation to the insured) mr/miss/master…………………………………….I further declare that his/her receipt shall be sufficient discharge to the company.
I further declare and warrant that the above statements are true and complete. I consent to the insurers seeking medical information from any doctor who has at any time attended concerning anything which affects my physical or mental health, and I authorise the giving of such information to Mercury International Assistance and Claims Ltd, & / or their programme medical advisors. I agree that
this proposal shall form the basis of the contract should the Insurance be affected.
I am willing to accept the policy, subject to the terms, exceptions and conditions prescribed therein.
Signature of Proposer: Date………./…………./…………
Place: Day Month Year
PROHIBITION OF REBATE
Section 41 of the 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 relation 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 prospectus or tables of the insurers.
2) Any person making default in complying with the provisions of the section shall be punishable with fine which may extend to five hundred ruppes.
(B) TO BE COMPLETED BY THE DOCTOR [To be completed by M.D. only]
1. (a) History
(b) Any past history of disease, operation,
accidents, investigations etc.
(c) General Examination
(d) Systemic Examination
2. Electrocardiography :
(a) Does the attached Electrocardiogram
in your professional opinion show any
abnormalities and if so, please describe.
(b) Does the abnormality represent a
current illness or disease which may
possibly require medical treatment
during peoposer’s forthcoming trip ?
(c) Does the proposer now or did he/she in
the past, require medication for this
(d) Please describe any treatment taken by Proposer in the past or being
taken at present
(e) Do you recommend Stress Test ? If so please obtain the report on such
3. Dose the urine Strip Test show any sugar ?
4. Do you consider that proposer is fit to travel any where abroad, due account being taken of the stress of air travel adversely affection his health/medical condition ?
Signature of the Doctor :
Name of the Doctor :
Telephone No. :