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1Proposer &
Contact Details -
2Insured Details
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3Medical Questions
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4Lifestyle Information
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5General Details
Plan Details
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Plan Type
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Sum Insured
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Family Combination
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Premium for
RS
Proposer Details Edit
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TPA Name
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First Name
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Last Name
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Gender
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Nationality
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Educational Qualification
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Martial Status
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Occupation
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Business
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Designation
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Pan No.
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Date of Birth
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Type of Address Proof
Contact Details Edit
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Address 1
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Address 2
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Address 3
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City
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State
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Pincode
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Mobile Number
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Residence Phone
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Email Id
Insured Details Edit
Adult 1
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Relationship with Proposer
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First Name
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Last Name
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Gender
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Date of Birth
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Height(Cms)
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Weight(Kgs)
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BMI
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Occupation
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Business
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Designation
Medical Questions Edit
Within the last 2 years have you consulted a doctor or healthcare professional? (other than Preventive or Pre-Employment Health Check-up)?
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Insured name1
Within the last 2 years have you undergone any detailed investigation other than Preventive or Pre-Employment Health Check-up (e.g. X-ray, CT Scan, biopsy, MRI, Sonography, etc)?
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Insured name1
Within the last 5 years have you been to a hospital for an operation/medical treatment?
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Insured name1
Do you take tablets, medicines or drugs on a regular basis?
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Insured name1
Within the last 3 months have you experienced any health problems or medical conditions which you/proposed insured person have/has not seen a doctor for?
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Insured name1
Have any of the person(s) proposed to be insured ever suffered from or taken treatment, or been hospitalized for or have been recommended to undergo / take investigations / medication / surgery or undergone a surgery for any of the following - Diabetes; Hypertension; Ulcer / Cyst / Cancer; Cardiac Disorder; Kidney or Urinary Tract Disorder; Disorder of muscle / bone / joint; Respiratory disorder; Digestive tract or gastrointestinal disorder; Nervous System disorder; Mental Illness or disorder, HIV or AIDS?
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Insured name1
Additional Medical Details Edit
Insured name1
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Name of illness/injury suffering from or suffered in the past
Date of first diagnosis
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Month
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Year
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Treatment/Medication
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Treatment outcome
Lifestyle Information Edit
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Insured Name 1
Do you consume Alcohol?
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Quantity(Beer - No. of Pints/week, Wine & Spirit - ml/week)
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No. of Years
Insured Name 1
Do you smoke?
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Quantity (No. of Cigarettes per day)
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No. of Years
Insured Name 1
Do you consume Tobacco/Gutka/Pan/Pan masala?
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Quantity (Pouch per day)
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No. of Years
Insured Name 1
Do you consume Narcotics?
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Quantity
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No. of Years
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If you had any of these habits in the past, please mention the year of stopping and the reason for doing the same
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Premium Amount
RS (Inclusive of all taxes)
Quote ID
Policy Start Date
Policy End Date
No. of Members