THE ORIENTAL INSURANCE COMPANY LIMITED,
HEAD OFFICE: A-25/27, ASAF ALI ROAD, NEW DELHI 110002

MEDICAL INSURANCE PROPOSAL FORM

PROPOSAL FORM NO. DATE:
1. FORM TO BE FILLED IN BLOCK LETTERS.
2. PLEASE SUBMIT TWO STAMP SIZE PHOTOGRAPHS OF EACH INSURED PERSON ALONGWITH TWO
COPIES OF PROPOSAL FORM. NAME AND AGE OF THE INSURED MUST BE WRITTEN ON THE BACK OF
THE PHOTO.
3. THE COMPANY WILL NOT BE ON RISK UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY
AND COMMUNICATION OF THE ACCEPTANCE HAS BEEN GIVEN TO THE PROPOSER IN WRITING ON
RECEIVING FULL PAYMENT OF PREMIUM.
4. IN CASE OF ADVERSE MEDICAL HISTORY ANNEXURE ‘A’ TO BE COMPLETED BY THE CONSULTING
PRACTITIONER (NOT BELOW MD) AND TO BE SUBMITTED BY THE PROPOSER.
5. ANNEXURE ‘A’ IS ALSO TO BE OBTAINED FOR PERSONS AGED ABOVE 50 YEARS AND BE SUBMITTED
ALONGWITH LATEST ECG PRINT OUT WITH REPORT AND FASTING BLOOD SUGAR TEST AND URINE
STRIP TEST REPORT OR ANY OTHER MEDICAL REPORT REQUIRED BY THE COMPANY.
1. NAME OF THE INSURED PERSON AND RELATIONSHIP WITH THE PROPOSER.
S.
No.
Name of the insured’s / proposer Relation
ship with
Proposer
Sex
M/F
Date of Birth Age Occup
ation
Sum
Insure
d (Rs)
1.
2.
3.
4.
5.
6.
7.
2. ADDRESS & TELEPHONE NO. / MOBILE NO. / E-MAIL ADDRESS
Mobile no
Ph.No E-mail
3.PERMANENT ACCOUNT NO. (ISSUED BY INCOME-TAX AUTHORITIES)
4.NAME - ADDRESS & TELEPHONE NO OF FAMILY PHYSICIAN
Ph.No Mobile No
5.PLEASE FURNISH DETAILS OF ANY OTHER INSURANCE AT PRESENT OR PAST AND CLAIM DETAILS IN THE
PAST YEARS.
S.
No
First Name of the insured Name of the Insurer Type of policy
(Please specify)
P.A., Cancer,
Mediclaim
others)
Policy
Number
Policy
Period
1.
2.
3.
4.
5.
6.
7.
2
6.CLAIM DETAILS IF ANY OF INSURED
S.No. of
Proposer
First Name of The Insured Amount
of Claim
Policy No. Policy Period Ailment for which amount
claimed
1.
2.
3.
4.
5.
6.
7.
7. PLEASE ANSWER THE FOLLOWING QUESTIONS IN YES / NO
SERIAL NO.OF PERSON IN PARA (1)
PARTICULARS 1 2 3 4 5 6 7
A. Are you in good health and free from
physical and mental diseases or infirmity or
major complaints ?
B. Have you ever suffered from any of the
following diseasee / illnesses. Please encircle
the disease and write Yes otherwise write No.
1 Any Neurological / mental or psychiatric
diseases?
2 slipped disc or other spinal disorder or
paralysis of any kind or fainting episode,
blackout, fit.
3 High blood pressure, Heart diseases
including ischaemic heart diseases, other
circulatory disorders including rheumatic
fever etc.
4 Diseases of uterus, ovaries, breast or any
other gynaecological disorder
5 Fistula, Piles, Hernia, Varicose veins.
6 Any disease of bones, joints Arthritis
including rheumatic diseases etc.
7 Any respiratory or allergic diseases
8 Any dimness of vision or cataract etc.
9 Any disease of ears or difficulty or
interference with hearing etc.
10 Any disorder of the stomach, ulcer, bowel
or gall bladder, kidney etc.
11 Cancer, malignant growth, boil, cyst or
wound etc.
12 Diabetes or any urinary diseases.
13 Any cerebral or vascular strokes or similar
disease.
14 (a) Have you ever suffered from dental
problems? YES/NO
(b) If, yes, specify same.
(c) When were you treated last for same.
15 Any other complaint requiring specialist’s
consultation or surgical or hospital
treatment or investigations.
16 Any other complaint or tendency that may
necessitate such consultation or treatment
in the future
3
8. PLEASE GIVE DETAILS OF DISEASES/ ILLNESSES/INJURIES DEFORMITIES ETC DECLARED YES IN
COLUMN NO. 7.
S.No Name of the insured person Nature of illness
/ disease / injury
Date
when first
treated
Name & Address
Of attending
medical
practitioners
Whether
fully
cured
1.
2.
3.
4.
5.
6.
7.
9. PLEASE STATE THE NAME OF PRE-EXISTING DISEASES / ILLNESS/ INJURIES SUFFERED /
SUFFERS BY THE PROPOSER.
S.No First Name of the insured person Name of disease / illness /injuries. Remarks
1.
2.
3.
4.
5.
6.
7.
10. ARE THERE ANY ADDITIONAL FACTS EFFECTING THE PROPOSED INSURANCE WHICH SHOULD
BE DISCLOSED TO THE INSURERS.
S.No First Name of the insured person Remarks
1.
2.
3.
4.
5.
6.
7.
11. PLEASE GIVE THE DETAILS OF EXISTING MEDICLAIM POLICY.
S.No First Name of the insured person Name of the
Insurer
Policy
no.
Sum Insured Period Remarks
1.
2.
3.
4.
5.
6.
7.
4
12. HAS THE PROPOSAL OF ANY OF THE MEMBERS OF FAMILY PROPOSED BEEN REFUSED/ HIGHER
PREMIUM CHARGED OR FACED DIFFICULTY IN SIMILAR PROPOSAL DUE TO:
S.No F i r s t Name of the insured Refusal by insurer Higher premium
charged on a/c
of
high claim ratio
Cancellation of
policy by
insurer
1.
2.
3.
4.
5.
6.
7.
13. NAME OF THE NOMINEE IN THE EVENT OF DEATH OF INSURED DURING THE COURSE OF
TREATMENT.
S.No. First Name of the Insured Name of the Beneficiary Relation with Insured
1.
2.
3.
4.
5.
6.
7.
14. PROPOSED DATE & PERIOD OF INSURANCE( DD MM YY)
I/we declare that the statements made by me/us in this proposal form are true and to the best of my / our
knowledge and belief and I/we hereby agree that this declaration shall form the basis of the contract between
me/us and The Oriental Ins.Co.Ltd.. I / we also declare that if any additions or alterations are carried out after the
submission of this proposal form and /or issuance of policy document, the same would be conveyed to the The
Oriental Insurance Company immediately. I further consent and authorize the Oriental Insurance Company
Limited and/or any of its authorized representative to seek medical information from any hospital/medical
practitioner who has attended or may attend in future concerning any disease or illness. I further declared that I
have read the prospectus and have understood the same. I accept the policy, subject to terms, exceptions and
conditions prescribed therein and further disclose that on the event of finding any thing contrary to what has been
declared by me, I shall be held responsible for all consequences thereof and insurance company shall incur no
liability under this insurance.
Place Signature of Proposer.
Date Name of Proposer
INSURANCE ACT 1938 SECTION 41 - PROHIBITION OF REBATES
Section 41 of the Insurance Act 1938 provides as follows:
Any person making default in complying with provision of this section shall be punishable with fine which may extend to
Rs.500/-.
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 prospectus or tables of the Insurer.
FROM To
5
ANNEXURE - A
MEDICAL CERTIFICATE
TO BE COMPLETED BY CONSULTING PHYSICIAN NOT BELOW MD.
S.No. 1. 2. 3. 4. 5. 6. 7.
1. Name of the
Insured
2. Age
3. Any Past History
of diseases /
operations /
investigation /
accident /
investigation with
date and major
complaints.
4. Details of past
medication
5. Blood Pressure
6. Pulse
7. General
Examination
8. Systemic
Examination
9. ECG Report and
observation
10. Blood / Urine
Report
11. Present
complaints
investigation, if
any.
12. Details of present
medication.
13. Remarks.
Signature of Poposer Signature of Physician
NAME OF THE PROPOSER
Name, Address and Seal
of physician with Registration No.
Place:
Date: