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E-mail:Mobile:
First Name Middle Name Surname
Address:
City: State: Pin:
Married SingleMarital Status:D D M M Y YDate of Birth:Gender: Male Female
Tel (Off): Tel (Res):
Personal details of the proposer, if different from Insured (Proposer can be blood relationship or Spouse)STEP 1 BSTEP 1 B
Name Date of Birth *Nominee's relationship with insuredNominee NameGender M/F
Spouse
1st child
2nd child
Additional insured informationSTEP 1 CSTEP 1 C
DD/M M/ Y Y Y Y
DD/M M/ Y Y Y Y
DD/M M/ Y Y Y Y
Nominee Name:*Nominee’sRelationship with Insured:
Personal details of the InsuredSTEP 1 ASTEP 1 A
E-mail:Mobile:
First Name Middle Name Surname
Address:
City: State: Pin:
Married SingleMarital Status:D D M M Y YDate of Birth:Gender: Male Female
Tel (Off): Tel (Res):
(Please fill the form in BLOCK Letters)
Wellsurance Family PolicyProposal Form
Proposal No.:
To help us serve you better, kindly ensure that the form is completely filled(This Insurance does not commence until the proposal is accepted and premium is realized by Tata AIG General Insurance Company Limited)
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WellsuranceFamily Policy
*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:
Appointee Name Relationship Address of the Appointee
Photo ID Type Photo ID Number :
Insured’s PAN Card Number : in the absence of PAN Card, please give details of any other authorized photo identification card.
Salary Business Other (Please specify)Sources of funds (please ü where applicable) :
Note: The Policy is valid subject to realisation of the premium by the company. In the event of non-realisation of the cheque or non-receipt of the premium by the company where payment has been made by a credit card (for any reason whatsoever), the Policy shall be deemed to be cancelled ’ab-initio’ and company shall not be responsible for any liabilities of whatsoever nature.
STEP 3STEP 3 Payment mode (Please the appropriate box)
Name of Bank: Branch:
(Please draw your cheque / DD in favour of Tata AIG General Insurance Company Limited)Cheque / Demand Draft No.: Date: Y YMDD M
Cash (Please note that tax exemption certificate will not be issued for cash payment)
Credit Card No.: (Only Visa / MasterCard accepted)
Expiry Date: M M Y Y
STEP 4STEP 4 Declaration (Health, Other Policies & AML Guidelines)
Name of the policy
Previous Policy No Insurer
Period of InsuranceSum
Insured (Rs)
Claims lodged during the preceding
3 years
Cumulative Bonus
Membership
no. of previous insurer for
each insured
From To(DD/MM/YY)
(DD/MM/YY)
Existing / Previous Health Insurance Policy details of any of the Person(s) proposed to be Insured
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Age Family Premium Rates (Self + Spouse + up to 2 children) - Option 1
Family Premium Rates (Self + Spouse) - Option 2
Family Premium Rates (Self + up to 2 children) - Option 3
STEP 2STEP 2 Premium chart (Please the appropriate box to indicate the plan)
Annual Premium in `
Classic Supreme Elite
18 - 24 c 4,049 c 7,147 c 12,441
25 - 29 c 4,610 c 7,980 c 13,546
30 - 34 c 5,740 c 9,670 c 15,795
35 - 39 c 7,563 c 12,377 c 19,386
40 - 44 c 11,297 c 17,941 c 26,780
45 - 49 c 13,072 c 20,595 c 30,312
50 - 54 c 17,909 c 27,821 c 39,928
55 - 59 c 23,254 c 35,746 c 50,433
60 - 65 c 37,207 c 57,193 c 80,694
66 - 70 c 55,809 c 85,791 c 121,041
71 - 75 c 83,715 c 128,686 c 181,561
76 - 80 c 125,572 c 193,029 c 272,342
81-90 c 251,144 c 386,059 c 544,683
>90 c 313,931 c 482,574 c 680,855
Premium Chart (inclusive of 18% GST). For more details on risk factors, terms and conditions please read the sales brochure before concluding the sale.Note: 1. Waiting period of 90 days for all Sickness Hospital Cash, 2. No waiting period for Accident related Hospitalisation 3. Waiting period of 90 days for Critical Illness Benefit, 5. Age Group – For self & spouse – 18 – 65 years, For Children – 6 months – 18 years (23 years incase of Higher education) 6 We offer lifelong renewal provided premium is paid without any break. 7. Premium will be applicable as per completed age as on last birthday. 8. Get tax benefits for premium paid on policies as per section 80D of the Income Tax Act 1961. Tax benefits are subject to changes in the tax laws.
The premium rates for age 66 and above years are only for renewal cases.
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Classic Supreme Elite
c 3,344 c 5,904 c 10,277
c 3,808 c 6,593 c 11,190
c 4,741 c 7,989 c 13,048
c 6,248 c 10,225 c 16,015
c 9,333 c 14,821 c 22,123
c 10,798 c 17,013 c 25,040
c 14,794 c 22,982 c 32,985
c 19,210 c 29,530 c 41,662
c 30,735 c 47,247 c 66,661
c 46,104 c 70,871 c 99,991
c 69,155 c 106,306 c 149,985
c 103,734 c 159,459 c 224,978
c 207,466 c 318,919 c 449,956
c 259,333 c 398,648 c 562,446
Classic Supreme Elite
c 2,817 c 4,971 c 8,654
c 3,207 c 5,552 c 9,423
c 3,993 c 6,727 c 10,988
c 5,262 c 8,610 c 13,486
c 7,859 c 12,481 c 18,630
c 9,094 c 14,326 c 21,087
c 12,458 c 19,353 c 27,776
c 16,177 c 24,867 c 35,084
c 25,883 c 39,787 c 56,135
c 38,824 c 59,681 c 84,202
c 58,237 c 89,521 c 126,304
c 87,354 c 134,282 c 189,455
c 174,708 c 268,563 c 378,911
c 218,386 c 335,703 c 473,638
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Insured Name
Name of Pre-ExistingDiseases/Illness/
Surgery
Diagnosis
Date
Date of last consultation
Treatment Inpatient / Outpatient
DoctorName
Hospital Name
Hospital STD code with
Phone No.
DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYY DD/MM/YYYY
DD/MM/YYYY DD/MM/YYYY
Medical Declaration1. Have you or any person proposed to be insured received any advice / treatment / consultation for any medical condition in the last 5 years: If yes, please specify details of Treatment, Institution and Doctor (Identify per family member) c Yes c No
SelfInsured Spouse 1st Child 2nd Child
Prescribed medication
Time in years (since)
2. I /we am/are presently taking specific medication:If yes, please name the prescribed medication you are taking (identify per family member)
c Yes c No
Date: Place: Signature of Proposer:
DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED :c I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured that the above statements, answers and/or particulars given by me are true and
complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons. c I understand that the information provided by me will form the basis of insurance policy, is subject to the Board approved underwriting policy of the Insurance company
and that the policy will come into force only after full receipt of the premium chargeable.c I/We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been
submitted but before communication of the risk acceptance by the company.c I/We declare and consent to the company seeking medical information from any doctor or from hospital who at anytime has attended on the life to be insured/proposer
or from any past or present employer concerning anything which affects the physical and mental health of the life to be assured/proposer and seeking information from any insurance company to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
c I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.
c I authorize Tata AIG General Insurance Company Limited and associate partners to contact me via e-mail, phone or SMS.
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Additional Information(If there is insufficient space to provide additional relevant information, whether as requested or otherwise, please extra sheet duly signed.)
l Nationality : Indian Non-Indian If Non-Indian, please specify the Country : l Type of Organization
Corporations Governments Non Governmental Organizations Society
Trust Partnership International Organization Cooperatives Section 25 Company
AML guidelines: 1. I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related to any of
the offence listed in prevention of Money Laundering Act, 2002. 2. I understand that the Company has the right to call for documents to establish sources of funds. 3. The insurance company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of law under any of the statutes, directly or
indirectly governing the prevention of money laundering in India.
in the absence of PAN Card, please give details of any other authorized photo identification card.PAN Card No.
Card Type ______________________
Sources of funds (please 3 where applicable)
Number :
Other (Please specify) ___________________________BusinessSalary
DeclarationThe content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood these and confirm to abide by the policy terms & conditions.Signature of the Proposer: ____________________________________________________________________________________________________Name & Signature of agent/intermediary: _______________________________________________________________________________________Code: _______________________________
Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print):The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the proposer who has understood and confirmed the same. Signature/Thumb impression of the Proposer: ___________________________________________________________________________________Name & Signature of agent/intermediary: ________________________________________________________________________________________
Application Number :
Address: Premium Amount : Rs. To be debited from
Cheque No.: Date: Branch :D D MM Y Y
ACKNOWLEDGMENT SLIPProposal form received from: Mr./Mrs./Ms.
Account of Mr / Ms. Account Holder Number:
Bank Name:“Commencement of risk cover under the policy is subject to receipt and realization of payable premium by Tata AIG General Insurance Company Limited”
Tata AIG General Insurance Company LimitedRegistered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013
24X7 Toll Free No: 1800 266 7780 Fax: 022 6693 8170 Email: [email protected] Website: www.tataaig.com IRDA Registration No: 108 CIN:U85110MH2000PLC128425
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Disclaimer: Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
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 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. 2. Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to ten lakh rupees.
Specified Person Details
SP Certificate No SP Name SP Signature
Name of the Account Holder:
Name of the Bank
Type of Account : SB Account Current Account Others (please specify)
Account Number :
IFSC Code of Bank :If the premium cheque is not paid from the above mentioned account then a cancelled cheque leaf of the above mentioned account is to be attached. #mandatory if annualized premium is more than Rs.25,000
Branch:
As per the Regulatory requirements ,we can effect payment of refund / claims only through Electronic Clearing System (ECS) / National Electronic Funds Transfer (NEFT) / Real Time Gross Settlement (RTGS) / Interbank Mobile Payment Service (IMPS). For this purpose please submit the following details of the insured's bank account#
Bank Details
Grievance Redressal Procedure: As per Regulation 17 of IRDA of India (Protection of Policy holders Interests) Regulation. 2017.
Ver8/Feb 2018
Agent Declaration:I,______________________________________________________________________ (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and response(s) submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of the Contract of Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy. I have further explained that if any untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to be furnished, the Company shall have the right to vary the benefits which may be payable and further more if there has been a non-disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal may be treated by the Company as null and void and all premiums paid under the Policy may be forfeited to the company.
License No.(Intermediary/Corporate Agent/Broker/Relationship Officer)
Name of the specified Person and code
Place: ___________________________
Date: Signature of Agent: __________________________________________
Section 64 VB of the Insurance Act 1938Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
