The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR BIRTHRIGHT INSURANCE POLICY

1.(a) Name of the expectant mother (proposer)

(b)Name of the father of the child (in full)

2.Address

3. Age
a) Proposer_____________ b) Father of the child___________
4. Occupation
a) Proposer_____________ b) Father of the child_______________
5. Are you in good health on the day of signing this proposal

6. Name of the physician /gynecologist who usually attends to you

7. Have you consulted your family physician or any other physician / gynecologist for any major ailment in the last six months prior to this proposal: If so give details

8. a) Are you a heavy smoker consumer of alcohol/narcotics ?
b) Are you suffering from cancer/diabetes/tuberculosis (T.B) ?
c)Has any member of your family or any ancestor suffered from congenital
anomalies?
d) Have you suffered or are you suffering from, any other systematic disease?

9. Have you undergone any radiation therapy for any reason whatsoever?
10. (a) Date of approximate delivery of child
(b) Is this your first pregnancy? If not please give details of earlier
pregnancy/pregnancies – Yes / No No. of Children Age

(c ) Has any child suffered from any congenital anomalies? If so give details

11. Blood group of proposer
12. Please specify category of Table and Benefit opted. I/II/III/IV

I, do hereby declare that the statement and answers under heading 1 to 12 of the proposal form have been given by me after having understood the questions fully, and that the same are true and complete in every particular. I agree and declare that these statement and this declaration shall be the basis of the contract of insurance between me and the Company and that if any untrue averment be contained therein, the said contract shall be absolutely null and void and all monies which have been paid in respect thereof shall stand forfeited to the Company. I hereby agree and undertake to take requisite treatment as prescribed by the Medical Practitioner in case I belong to the RH-negative blood group.

Witness Proposer’s Signature
Signature Date:
Name
Address-

CERTIFICATE
I have examined the expectant mother and certify that she is approximately _________ weeks pregnant that she is in sound health and that the approximate date of delivery of the child is _______
I certify that the expectant mother (proposer) does not belong to RH Negative blood group copy of the report enclosed.

Date: Signature of Registered Medical
Practitioner/Gynecologist
Name
Reg. No.
N.B.: Certificate should be obtained from a duly qualified allopathic doctor, holding a minimum qualification of MBBS from a recognized university.
Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid. 2. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
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 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 rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.