Health Insurance Proposal Form - United India Insurance

Important: This Proposal Form shall be the basis of the policy. Please provide all information fully & accurately.

I. Proposer Details

Full Name *

Date of Birth *

Gender *

Marital Status *

Occupation *

Specify Occupation

PAN (or Form 60/61)

Aadhaar / Passport

E-Insurance Account

Present Address *

Permanent Address *

Present City *

Present State *

Present Pin *

Permanent City *

Permanent State *

Permanent Pin *

Telephone

Mobile *

Email ID *

Proposer Signature *

Click to upload signature

II. Policy Period

Proposal Date *

Expiry Date *

III. Nomination

Nominee Name *

Relationship *

Nominee Mobile

Nominee Address

Nominee Email

Bank A/c Number

IFSC Code

IV. Coverage Details

Policy Type *

Sum Insured *

Daily Cash Allowance

TPA Preference

Maternity & New Born

Intermediary Code

Tip: 1st Insured is the Proposer. Click tabs below to add members. For other members, 1st insured is deemed to be the Nominee.

1st Insured

2nd Insured

3rd Insured

4th Insured

5th Insured

6th Insured

Auto-filled from Proposer Details

Name *

DOB *

Gender *

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height (cm)

Weight (kg)

Blood Group

Relation *

Dependent

Photo

Click to upload

Signature

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Name

DOB

Gender

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height

Weight

Blood Group

Relation

Dependent

Photo

Click to upload

Signature

Click to upload

Name

DOB

Gender

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height

Weight

Blood Group

Relation

Dependent

Photo

Click to upload

Signature

Click to upload

Name

DOB

Gender

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height

Weight

Blood Group

Relation

Dependent

Photo

Click to upload

Signature

Click to upload

Name

DOB

Gender

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height

Weight

Blood Group

Relation

Dependent

Photo

Click to upload

Signature

Click to upload

Name

DOB

Gender

Marital

ABHA ID

Occupation

Aadhaar

Sum Insured

Height

Weight

Blood Group

Relation

Dependent

Photo

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Signature

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VI. Existing Health Cover Information

Does any person proposed hold a health insurance policy from any insurer (including UIIC)?

Note: Kindly fill Annexure C if porting. Continuity of benefits shall NOT be considered if details are not provided.

Medical History of the person proposed for Insurance. Tick Yes/No. Please do not leave the spaces blank.

▶ A. Lifestyle Questionnaire

Question	1st	2nd	3rd	4th	5th	6th
Alcohol Consumption
Tobacco (Bidi/Cigarette/E-Cig/Gutkha/Pan Masala)

▶ B. Mental Health Questionnaire

Question	1st	2nd	3rd	4th	5th	6th
Diagnosed/treated for psychological/mental health condition?
Undergone Hospitalisation/Psychological Counselling?

▶ C. Specific Condition Questionnaire

Cardiovascular System

Condition	1st	2nd	3rd	4th	5th	6th
Heart Diseases, Chest Pain, Heart Attack, Angina, Palpitations, Angioplasty/Bypass, High BP, Paralysis, Blood Clotting

Respiratory System

Condition	1st	2nd	3rd	4th	5th	6th
Asthma, COPD, Chronic Bronchitis, TB, Pneumonia, Interstitial Lung Disease

Digestive System

Condition	1st	2nd	3rd	4th	5th	6th
Stomach, Intestines, Liver, Gall Bladder, Pancreas disorders

Genitourinary System

Condition	1st	2nd	3rd	4th	5th	6th
Kidney, Urinary bladder, Urinary tract OR Prostate/Reproductive disorders

Endocrine & Metabolic

Condition	1st	2nd	3rd	4th	5th	6th
Diabetes (Type I/II), Prediabetes, Dyslipidaemia, Thyroid disorders

Nervous System

Condition	1st	2nd	3rd	4th	5th	6th
Epilepsy, Seizures, Stroke, Parkinson's, Multiple sclerosis, Neurological disorders

Musculoskeletal System

Condition	1st	2nd	3rd	4th	5th	6th
Arthritis, Spinal Injury, Avascular Necrosis, Fractures, Musculoskeletal disease

Skin & Connective Tissues

Condition	1st	2nd	3rd	4th	5th	6th
Psoriasis, Eczema, Vitiligo, Chronic Skin Conditions

Haematological System

Condition	1st	2nd	3rd	4th	5th	6th
Anaemia, Thalassemia, Haemophilia, Bleeding/Clotting disorders

Immune System / Autoimmune Disorders

Condition	1st	2nd	3rd	4th	5th	6th
Lupus, Rheumatoid Arthritis, IBD, HIV, Autoimmune disease

Oncology

Condition	1st	2nd	3rd	4th	5th	6th
Cancer, Tumour, Pre-Cancerous condition

Eyes

Condition	1st	2nd	3rd	4th	5th	6th
Vision loss, Glaucoma, Cataract, ARMD, Visual Aids/Surgery

ENT

Condition	1st	2nd	3rd	4th	5th	6th
Any disease of the Ear, Nose or Throat

D. Disability Related Questionnaire

Condition	1st	2nd	3rd	4th	5th	6th
Locomotor Disability, Leprosy Cured, Acid Attack, Cerebral Palsy, Muscular Dystrophy, Dwarfism, Visual/Hearing Impairment, Speech/Language Disability, Autism, Intellectual Disability

E. General Medical Questionnaire

Question	1st	2nd	3rd	4th	5th	6th
More than two Hospitalizations in previous 2 years (except vector/air/water-borne <5 days)
Any Surgery/Treatment, consultations, investigations planned or pending
Pain >7 days, Movement restriction, Difficulty swallowing/breathing, Daily activity difficulty, Persistent headache/cough, Blood in stool >5 days
Currently taking prescription medications or undergoing ongoing medical treatments?

If you answered 'Yes' to any questionnaire: Please give details below and submit Annexure A.

Medication/Treatment Details

Person	Illness	Treatment	Doctor	Hospital & Phone	Status	Last Consult

VII. Past Proposal & NCB Details

Note: If you have held a health insurance policy previously, please provide details for No Claim Bonus (NCB) continuity.

Has any proposal ever been declined / accepted at extra premium / modified terms?

Have you held a health policy before?

VIII. Bank Details for Processing of Refund (Optional)

Account Holder Name

Bank Name

Account Number

IFSC Code

Account Type

Branch

IX. Physical Copy Preference

Do you wish to receive policy document in physical form, in addition to electronic copy?

X. National Health Authority (NHA) Declaration

I confirm that I have read the terms of usage of Aadhaar for the creation of ABHA Number. I consent to the usage of my Aadhaar Number(s) by UIIC for the creation of my ABHA Number(s) through the National Health Authority (NHA).

XI. Declaration on behalf of all persons proposed to be insured

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the statements, answers and particulars given by me/us are true and complete in all respects to the best of my knowledge and that I am authorised to propose on their behalf.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of United India Insurance Company and that the policy will come into force only after receipt of premium.

I agree that the company shall not be bound to accept any proposal and the company has the right to decline any proposal or require me to furnish additional information. I also agree that in the event of any change in the occupation or general health of the life to be insured occurring after the proposal has been submitted but before the communication of the risk acceptance by the company, I shall intimate the company in writing of such change.

I consent to the company to seek medical information from any doctor or hospital who/which at any time attended on the life to be insured. I authorize the company to share information with other insurers, CIBIL, etc. for the purpose of risk assessment, fraud detection or compliance. I consent to UIIC collecting, processing, storing, verifying and sharing my personal and sensitive personal information in accordance with the Digital Personal Data Protection Act, 2023.

Declaration Details

Place *

Date *

Proposer Name *

Proposer Signature *

Click to upload signature

XII. Declaration of the Intermediary

I confirm that I have explained the product features to the proposer and its suitability to him/her and other insured persons.

Intermediary Name

Intermediary Code

Date

Intermediary Signature

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XIII. Statutory Warning (Section 41 of Insurance Act, 1938)

Warning: 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 insurance, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy. Any person making default shall be punishable with fine which may extend to ten lakh rupees.

XIV. Office Use Only

Proposal No

Receipt No

Date

Development Officer Code

Branch Code

Remarks

✅ Success Message:
Your proposal has been submitted. You will receive a confirmation email shortly.

Annexure – A: To be completed by EACH insured person who has answered 'Yes' to any question in Medical History or has any pre-existing conditions.
If all answers are 'No', Name, Date, Place and Signature will appear with "N.A" for all other fields.

1st Insured Person 1

Name of Insured Person

Date

Place

Date

Place

Signature of Insured Person

Click to upload

2nd Insured Person 2

Name of Insured Person

Date

Place

Date

Place

Signature

Click to upload

3rd Insured Person 3

Name

Date

Place

Date

Place

Signature

Click to upload

4th Insured Person 4

Name

Date

Place

Date

Place

Signature

Click to upload

5th Insured Person 5

Name

Date

Place

Date

Place

Signature

Click to upload

6th Insured Person 6

Name

Date

Place

Date

Place

Signature

Click to upload

Details	1st	2nd	3rd	4th	5th	6th
Company
Policy No.
Type
Expiry
Sum Insured
TPA
Last Claim
Claim Amt
Porting

Details	1st Person	2nd Person	3rd Person	4th Person	5th Person	6th Person
Previously Held Policy?
Previous Insurer
Previous Policy No.
Previous Policy Type
Previous Sum Insured
Policy Start Date
Policy End Date
NCB Eligible?
NCB Percentage (%)
Claim in Previous Policy?

🏥 Health Insurance Proposal Form

I. Proposer Details

II. Policy Period

III. Nomination

IV. Coverage Details

VI. Existing Health Cover Information

If Yes, provide details:

Cardiovascular System

Respiratory System

Digestive System

Genitourinary System

Endocrine & Metabolic

Nervous System

Musculoskeletal System

Skin & Connective Tissues

Haematological System

Immune System / Autoimmune Disorders

Oncology

Eyes

ENT

D. Disability Related Questionnaire

E. General Medical Questionnaire

Medication/Treatment Details

VII. Past Proposal & NCB Details

VIII. Bank Details for Processing of Refund (Optional)

IX. Physical Copy Preference

X. National Health Authority (NHA) Declaration

XI. Declaration on behalf of all persons proposed to be insured

Declaration Details

XII. Declaration of the Intermediary

XIII. Statutory Warning (Section 41 of Insurance Act, 1938)

XIV. Office Use Only