STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Acknowledgement
Received the proposal for ___________________________________________________________________________________________ policy from Mr/ Mrs/ Ms.__________________________________________________________________ along with
payment of Rs._________________/- by Cash / vide Cheque/ DD No. ___________________________dt._________________________ drawn on _____________________________. The Cash/Cheque given by you is banked for operational convenience
and banking of the Cash/Cheque does not mean acceptance of risk by us. The receipt of the Cash/Cheque will also be acknowledged by our office vide collection receipt. If the proposal is accepted, the cover will commence from the policy start date as stated in
Proposal Form No.:

the policy schedule, subject to realization of the Cheque. If the proposal is not accepted, the amount paid will be refunded. Contact our office, in case policy is not received within 15 days from the date of payment of premium.
Date: Place: Name & Code of the authorised person: Signature of the authorised person:

Common Proposal Form 2 4 of 4

Please affix
Please affix Please affix Please affix Please affix
stamp size
stamp size stamp size stamp size stamp size
photograph
photograph photograph photograph photograph
of Insured
of Insured of Insured of Insured of Insured
Person - 1
Person - 2 Person - 3 Person - 4 Person - 5

Submitted the above proposal for _____________________________________________________________________________ policy along with payment of Rs._______________________________ by cash/vide cheque/DD no.________________________

dated ______________________________ drawn on ____________________. I understand that the cash/cheque given is banked for operational convenience and commencement of risk is subject to the acceptance of proposal by you.

Declaration
The primary duty of the proposer is to fill out the proposal form and also to make sure that the proposal contains all the details correctly. If you or any of the insured person(s) have suffered or suffering from any of the diseases which has not been mentioned in
the proposal, the claim that may arise will result in a repudiation of the claim/cancellation of the policy.
I/we agree that the PAN details and other information provided by me/us in the proposal form may be used by the Company to download/ verify / modify / add my/our KYC documents from the CERSAI* CKYC portal for processing this application. I/We understand that only
the acceptable officially valid documents would be relied upon for processing this application. (*Central Registry of Securitization and Asset Reconstruction and security Interest of India) I hereby consent to receiving information from Central KYC Registry through SMS /
email on the above registered number/email address.
1. I 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 am authorized to propose on behalf of these
other persons. 2. 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 the insurer and that the policy will come into force only after full payment of the premium chargeable. 3. I further
declare that I 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. 4. I declare that I consent to the company
seeking medical information from any doctor or from a hospital who/which at anytime has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer
and seeking information from any insurer to whom an application for insurance on the person to be insured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement. 5. I authorize the company to share information pertaining to my
proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and /or claims settlement and with any Governmental and/or Regulatory authority. I confirm that the payment is made through my card / bank account. I also
confirm that the source of funds for premium paid under this policy is legal. I hereby confirm that the features of the product have been understood by me. I hereby authorize Star Health and Allied Insurance Company to contact me. It will override my registry on the NCPR.

Place Date Name

Signature / Thumb
impression of the
proposer:

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
LANGUAGE OF THE PROPOSAL FORM. the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
have fully understood the significance of the an inducement to any person to take out or renew or continue an
I hereby confirm that the details have been explained to the proposer. insurance in respect of any kind of risk relating to lives or property in
proposed contract.
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
prospectuses or tables of the insurer.

Date Name of the person who explained Signature of the person who explained Signature / Thumb impression of the proposer 2. Any person making default in complying with the provisions of this
section shall be liable for a penalty which may extend to ten lakh rupees.

Beware of spurious phone calls and fictitious/fraudulent offers and never respond to calls/emails/embedded links in SMS/emails asking you to update User id/Password/Credit Card Number/CVV/OTP etc.
Insurance is a contract of the utmost good faith, requiring the insured to answer all of the questions on the proposal form honestly and without omitting any information that is relevant. When submitting the proposal form, kindly reveal all pertinent information. If any important
information is omitted from the proposal form, personal statement, declaration, or related papers, or if the proposer or someone acting on his behalf makes any false or erroneous statements, misrepresentations, or omissions, the Policy will be invalid, at the insurer's
discretion. Please get in touch with the company's offices or agents if you have any questions about the proposal form.

†
Name
Name
Mother

Annual

Nomination
Date of Birth

GST Number
Business Type

CKYC Number
Income (in Rs.)
Proposer Name

Father / Spouse
(same as KYC/ID proof)

Source of Income

Please choose the

Policy Term Opted
:
D

State

Mobile
tick)

Village
Current Address District
If Yes
Prefix

Number
D

(please

Pincode

support of ID and Address††

Please attach any one proof

1 yr
through insurance repository
the KYC details provided here

in
City / Town /

Country and
M

Salaried

Address line 2
Address line 1
Do you wish to update CKYC with
M

to the proposed insurance policy

policy and all the information related
I would like to receive my insurance
Nominee’s Name :
Name of the Appointee

2 yrs
(if nominee is a minor) :
Y
Policy Issuing Office

††
Yes

Biennial for 2 year term / Triennial for 3 years

Y

Voter ID

No
enclosed duly specifying the % to each nominee)
Business

Premium can also be paid: Annually for 1 year term /

If
Y

Unorganized Sector

you
First Name

No PEP
Common Proposal Form 2 - Unique Reference No.: SHAI/PR0069

Other Categories of Persons

Others,

Exp Dt.:
PAN Number†

Period of
3 yrs Insurance
already
Gender

Driving License

have

From
an

Do you want to pay the

premium in Instalments
D
AGENT /
AGENT /

PROPOSER DETAILS
SM CODE

SM NAME

IMF / CODE

IMF / NAME

Male

Relationship
Relationship
CORPORATE
CORPORATE

Informal Sector

to Nominee :
to Proposer :

Yes Account (eIA) number, please provide:

Card
Do you come under below mentioned Social Sector Classification*

Aadhar
AGENT / BROKER /
AGENT / BROKER /

Yes
e-Insurance If

D M M
Proof)

you
address
same as
Address
(should be
Permanent

†††
Policy No.: ________________________________________________
Ref. No.: __________________________________________________

No
Female

Email ID
please specify ______________ to be submitted
Proof of Income

don’t
(Politically Exposed Person) or related to PEP

Y
Exp Dt.:
Middle Name

Passport
Yes

Are you (Proposer) or any of the insured person is†††a

Birth
Birth
State

have
Village

Date of
Date of
District

Y
Pincode
Alternate

Insurance Repository
choose any one
(elA) number, please
an
IT

City / Town /

Country and

Y
D
D
Residential Status
Economically Vulnerable or Backward Classes

Returns
No

Address line 2
Address line 1
Yes

Mobile Number

important political party officials, etc., including their family members and close relatives.
(Please check the brochure for policy term and Instalment facility in respect of each product)
D
Transgender

Whatsapp / Any other electronic mode

Instalment option)
Karvy

To
If yes (Please choose
M
PRO / COMMON 2 / V.1 / 2022

3mths

Indian

Email : [email protected] | Website : www.starhealth.in | CIN : L66010TN2005PLC056649 | IRDAI Regn. No. : 129
D
D M M
M
Payslip

NREGA
Resident

Job Card

CDSL Insurance
Insurance
No provide

Repository Limited
Repository Limited
Occupation

Y
Y

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office : 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. | Phone : 044 - 28288800
If yes, please

Y
Y
NRI
Are you a ASHA worker
Proposal Form No.:

Quarterly
Are you a MGNREGA worker

Y
Y

D M M
(Incase of Multiple nominees a separate form containing nominee details should be Do you wish to receive the copy of the policy document by Email /
Document

CAMS
Other Proof,
Last Name

Y
PIO
repair and maintenance, construction, personal and domestic services and manufacturing, with the work mostly labour intensive, having often unwritten and informal employer-employee relationship.

Y
Yes
Yes
Yes

Y Age
Y Age

Services Limited
Insurance
photograph

Repository (NIR)
Please affix
Passport size
PLEASE FILL UP THE FORM IN BLOCK LETTERS

of the Proposer

Rural and Social Sector Classification

Y
Any Other Govt. Notified
If PAN number is not available submit Form 60†

prominent public functions in a foreign country, example, Heads of State or of Governments, senior politicians, senior government / judicial / military officials, senior executives of state owned corporations,
accepted and full payment of premium has been received.
The company will not be on risk until the proposal has been

Halfyearly
NSDL National Insurance
Foreign

Y
in
in
National

The copy of PAN card or Form 60 is mandatory | If CKYC number is provided, proof of submission is not mandatory | Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with
No
No
No

yrs
yrs
Backward Classes” means persons who live below the poverty line. (c) “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of
cutters, tendu leaf collectors, toddy tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and coolies or such other categories of persons.(b)“Economically Vulnerable or
* “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural and urban areas; (a) “Unorganised sector” includes self-
1 of 4

Rights and Full Participation) Act, 1995 and who may not be gainfully employed; and also includes guardians who need insurance to protect spastic persons or persons with disability. (d) “Informal Sector” includes
employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers, fishermen, hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather

small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of generating employment and income, with heterogeneous activities like retail trade, transport,
and tannery workers, papad makers, powerloom workers, physically handicapped self-employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane

please specify_______________

details________________________

Repository
Common Proposal Form 2 2 of 4

Star Women Care Insurance Policy Star Health Assure Insurance Policy Star Health Premier Insurance Policy
Unique Identification Number: SHAHLIP23132V022223 Unique Identification Number: SHAHLIP23131V022223 Unique Identification Number: SHAHLIP22226V012122

Family 1A 1A 1A
Policy Type (Please ü) Cheque Debit Card NEFT
Individual Floater
Size
1A 1C+ 2C+ 3C+ Premium
Rs.
Sum Insured on A=Adult, 2A 2A 2A Amount Mode of
Rs. DD Credit Card Cash
Floater Basis in Lakhs** C=Child 2A 1C+ 2C+ 3C+ Payment
Applicable for Star Health Assure Insurance Policy CC (Cash payments are not eligible
ECS
Floater Sum Insured Account Mandate for the 80D tax benefits)
Number __________________________________________ Name of
Number of Parents / Parents-in-law the Bank : ____________________________________ Cheque / DD No. :
(as part of the same floater sum insured) Bank Type of Account
Do you wish to choose Deductible option c Yes c No Details of Name of
the the Branch : ____________________________________ Payment Date : D D M M Y Y Y Y
Savings Account Current Account
If yes, choose Proposer Details
Deductible Option c Rs.50,000/- c Rs.1,00,000/- IFSC
(Please Tick) Code : ____________________________________ Branch :
Others
**Please check brochure for the available sum insured option in respect of Please Specify _______________________________
each product. Please attach a photo copy of cancelled cheque leaf
Details of the person/s proposed for Insurance Insured Person - 1 Insured Person - 2 Insured Person - 3 Insured Person - 4 Insured Person - 5
Name
Gender Date of Birth M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY
Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS CMS KGS
Relationship with proposer
Occupation Annual Income (Rs.)
Sum Insured Opted (For Individual Policy) (Rs.)
Applicable for Star Women Care Insurance Policy c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
Do you want optional Cover (Applicable only for Females)
If yes, Please mention Sum Insured Opted (Rs.) for Optional Cover
Applicable for Star Health Assure Insurance Policy (Individual Policy) c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
Do you wish to choose Deductible option
If yes, choose deductible (Rs.) c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/-
1. Name of the Insurance Company
Existing Insurance
Coverage with us 2. Period of Insurance
and/or any other 3. Sum Insured (Rs)
company give details
4. Policy No.
Details of 1. Ailment for which Claim was made Year YYYY YYYY YYYY YYYY YYYY
Claims 2. Claim Amount Paid / Rejected
Have you ever been declined health insurance coverage due to a diagnosis of a health condition?
Health History: Please provide detailed, response-specific diagnosis and treatment.
A mere dash is not sufficient Family Physician's Name:_____________________________________________Phone:________________________________________Regn No:____________________________________
Note : If any of the below mentioned questions from "1 to 9" is "YES" and if additional space is needed to provide medical condition in detail, please enclose a seperate sheet along with this proposal form.
1. Is the person proposed for insurance in good health free from physical and mental disease or
infirmity. If not give details
2. Has the person proposed for insurance consulted / diagnosed / taken treatment / been admitted for
any illness / injury. If yes, give details
3. Does the person proposed for insurance have any complications during / following birth. If yes,
please submit all necessary documents.
4. Whether the insured person is pregnant if yes, kindly provide duration of pregnancy and scan reports.
5. Has the person proposed for insurance ever suffered or suffering from any of the following
a) Diabetes Mellitus –if yes, mention the duration/date of diagnosis, Type and medication details.
b) High BP/ Cholesterol – if yes, mention duration/date of diagnosis and medication details
c) Thyroid disorders, specify diagnosis Hypo / Hyperthyroid / Autoimmune thyroiditis, Goitre etc),
duration/date of diagnosis and medication details
d) Heart and vascular disease / Arrhythmias / valvular diseases / Cardiomyopathy – if yes, mention
duration/date of diagnosis, medication details, Intervention done, CAG, PTCA, CABG and others)
e) Stroke, epilepsy, fainting attack, chronic headache, Parkinson's disease, Alzheimer's disease,
mental disease or infirmity? – if yes, mention the duration/date of diagnosis and medication details
f) Tuberculosis, asthma, COPD, ILD, other respiratory diseases if yes, mention – duration/date of
diagnosis and medication details

g) Disease of bones/joints, slipped disc, spinal disorder, injury to ligaments – if yes, mention
duration/date of diagnosis and operation or treatment details
h) Whether diagnosed to have arthritis (Rheumatoid / Osteo arthritis or any other inflammatory
arthritis like Ankylosing spondylitis). If yes, mention treatment details and submit all records
ii) Gynecological disorder such as menstrual irregularity (DUB), fibroid uterus, ovarian cyst- or have
undergone cesarean / hysterectomy – if yes, mention duration/date of diagnosis and medication details
j) Treatment for sub-fertility or has been advised for? (answer if applicable – if yes, mention
duration/date of diagnosis and medication details
k) Disease of stomach, intestine, liver, gall bladder / Pancreas, Piles / Fistula / Fissure / Hernia if
yes, mention duration/date of diagnosis and medication details
l) Disease of kidney, urinary bladder, urinary tract disease, Calculi- if yes, duration/date of
diagnosis and medication details
m) Disease of prostate / hydrocele / genital disease / - if yes, mention duration/date of diagnosis
and medication details
n) Diseases of the eye, Cataract / corneal / retinal, other disorders and Ear, Nose Throat disease –if
yes, mention duration/date of diagnosis and medication details
o) Cancer, Precancerous lesions, Non-healing ulcers – if yes, mention type of cancer, duration/date
of diagnosis and treatment details
p) Any blood disorder, specify the diagnosis, mention duration/date of diagnosis and medication details
q) Any autoimmune disease / any long-term steroid / Immunosuppressant intake like myasthenia
gravis / SLE / Psoriasis, Ulcerative Colitis, Crohn's disease etc.) duration/date of diagnosis and
medication details.
r) Any other Health problems/diseases please specify
6. Has the person proposed for insurance
a) Undergone any medical test?
b) Prescribed any medicines? If yes
1. Name the illness for which medicines have been prescribed
2. Details of medicines and drugs prescribed
3. Period for which these drugs were taken
c) Been advised for any surgery/treatment? – If yes, give details
d) Received / received any payment for any disability / injury / illness / diseases. Give details
7. Does the person proposed for insurance has any of the mentioned habits
a) Chew Tobacco - If yes, since when
b) Smoke - If yes, since when
c) Consume Alcohol - If yes, since when
d) If a, b and c, are mentioned as yes, mandatory to give details whether diagnosed with any local
or systemic disease / complications.
8. Is the person proposed for insurance positive for HIV, Hepatitis B/C If yes, mention duration/date of
diagnosis, medication details, CD4 count (please attach proof) and Viral load
9. Type and the total number of medical documents provided
Applicable for STAR WOMEN CARE INSURANCE POLICY (Specific Questions for Female)
A) Is the person proposed for insurance presently pregnant? (If Yes, please submit the scan reports c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
taken during 12th and 20th week of Pregnencry period, at Star Health specified scan centres and
mention the expected date of delivery). Applicable for Female Insured Persons
B) Any complaint of Diabetes, Hypertension or any complication during current or earlier pregnancy?
C) Has the person proposed for insurance ever undergone hysterectomy or ever had any disease of
uterus, cervix or ovaries?

Declaration of the Agent / Intermediary : I / We confirm that the product‘s suitability has been explained to
the proposer. The information furnished in the proposal is true to the best of my knowledge and
recommend acceptance of the proposal. (Please Enclose Insurance Agent’s Confidential Report, If Any) Name of the Agent / Specified Person of Signature of the Agent / Specified Person of
Date Code Corporate Agent / Broker Qualified Person / Corporate Agent / Broker Qualified Person /
Insurance Sales Person of the IMF Insurance Sales Person of the IMF
Common Proposal Form 2 3 of 4
Common Proposal Form 2 2 of 4

Star Women Care Insurance Policy Star Health Assure Insurance Policy Star Health Premier Insurance Policy
Unique Identification Number: SHAHLIP23132V022223 Unique Identification Number: SHAHLIP23131V022223 Unique Identification Number: SHAHLIP22226V012122

Family 1A 1A 1A
Policy Type (Please ü) Cheque Debit Card NEFT
Individual Floater
Size
1A 1C+ 2C+ 3C+ Premium
Rs.
Sum Insured on A=Adult, 2A 2A 2A Amount Mode of
Rs. DD Credit Card Cash
Floater Basis in Lakhs** C=Child 2A 1C+ 2C+ 3C+ Payment
Applicable for Star Health Assure Insurance Policy CC (Cash payments are not eligible
ECS
Floater Sum Insured Account Mandate for the 80D tax benefits)
Number __________________________________________ Name of
Number of Parents / Parents-in-law the Bank : ____________________________________ Cheque / DD No. :
(as part of the same floater sum insured) Bank Type of Account
Do you wish to choose Deductible option c Yes c No Details of Name of
the the Branch : ____________________________________ Payment Date : D D M M Y Y Y Y
Savings Account Current Account
If yes, choose Proposer Details
Deductible Option c Rs.50,000/- c Rs.1,00,000/- IFSC
(Please Tick) Code : ____________________________________ Branch :
Others
**Please check brochure for the available sum insured option in respect of Please Specify _______________________________
each product. Please attach a photo copy of cancelled cheque leaf
Details of the person/s proposed for Insurance Insured Person - 1 Insured Person - 2 Insured Person - 3 Insured Person - 4 Insured Person - 5
Name
Gender Date of Birth M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY M / F / Transgender DD/MM/YYYY
Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS CMS KGS
Relationship with proposer
Occupation Annual Income (Rs.)
Sum Insured Opted (For Individual Policy) (Rs.)
Applicable for Star Women Care Insurance Policy c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
Do you want optional Cover (Applicable only for Females)
If yes, Please mention Sum Insured Opted (Rs.) for Optional Cover
Applicable for Star Health Assure Insurance Policy (Individual Policy) c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
Do you wish to choose Deductible option
If yes, choose deductible (Rs.) c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/- c Rs.50,000/- c Rs.1,00,000/-
1. Name of the Insurance Company
Existing Insurance
Coverage with us 2. Period of Insurance
and/or any other 3. Sum Insured (Rs)
company give details
4. Policy No.
Details of 1. Ailment for which Claim was made Year YYYY YYYY YYYY YYYY YYYY
Claims 2. Claim Amount Paid / Rejected
Have you ever been declined health insurance coverage due to a diagnosis of a health condition?
Health History: Please provide detailed, response-specific diagnosis and treatment.
A mere dash is not sufficient Family Physician's Name:_____________________________________________Phone:________________________________________Regn No:____________________________________
Note : If any of the below mentioned questions from "1 to 9" is "YES" and if additional space is needed to provide medical condition in detail, please enclose a seperate sheet along with this proposal form.
1. Is the person proposed for insurance in good health free from physical and mental disease or
infirmity. If not give details
2. Has the person proposed for insurance consulted / diagnosed / taken treatment / been admitted for
any illness / injury. If yes, give details
3. Does the person proposed for insurance have any complications during / following birth. If yes,
please submit all necessary documents.
4. Whether the insured person is pergnant if yes, kindly provide duration of pregnancy and scan reports.
5. Has the person proposed for insurance ever suffered or suffering from any of the following
a) Diabetes Mellitus –if yes, mention the duration/date of diagnosis, Type and medication details.
b) High BP/ Cholesterol – if yes, mention duration/date of diagnosis and medication details
c) Thyroid disorders, specify diagnosis Hypo / Hyperthyroid / Autoimmune thyroiditis, Goitre etc),
duration/date of diagnosis and medication details
d) Heart and vascular disease / Arrhythmias / valvular diseases / Cardiomyopathy – if yes, mention
duration/date of diagnosis, medication details, Intervention done, CAG, PTCA, CABG and others)
e) Stroke, epilepsy, fainting attack, chronic headache, Parkinson's disease, Alzheimer's disease,
mental disease or infirmity? – if yes, mention the duration/date of diagnosis and medication details
f) Tuberculosis, asthma, COPD, ILD, other respiratory diseases if yes, mention – duration/date of
diagnosis and medication details

g) Disease of bones/joints, slipped disc, spinal disorder, injury to ligaments – if yes, mention
duration/date of diagnosis and operation or treatment details
h) Whether diagnosed to have arthritis (Rheumatoid / Osteo arthritis or any other inflammatory
arthritis like Ankylosing spondylitis). If yes, mention treatment details and submit all records
ii) Gynecological disorder such as menstrual irregularity (DUB), fibroid uterus, ovarian cyst- or have
undergone cesarean / hysterectomy – if yes, mention duration/date of diagnosis and medication details
j) Treatment for sub-fertility or has been advised for? (answer if applicable – if yes, mention
duration/date of diagnosis and medication details
k) Disease of stomach, intestine, liver, gall bladder / Pancreas, Piles / Fistula / Fissure / Hernia if
yes, mention duration/date of diagnosis and medication details
l) Disease of kidney, urinary bladder, urinary tract disease, Calculi- if yes, duration/date of
diagnosis and medication details
m) Disease of prostate / hydrocele / genital disease / - if yes, mention duration/date of diagnosis
and medication details
n) Diseases of the eye, Cataract / corneal / retinal, other disorders and Ear, Nose Throat disease –if
yes, mention duration/date of diagnosis and medication details
o) Cancer, Precancerous lesions, Non-healing ulcers – if yes, mention type of cancer, duration/date
of diagnosis and treatment details
p) Any blood disorder, specify the diagnosis, mention duration/date of diagnosis and medication details
q) Any autoimmune disease / any long-term steroid / Immunosuppressant intake like myasthenia
gravis / SLE / Psoriasis, Ulcerative Colitis, Crohn's disease etc.) duration/date of diagnosis and
medication details.
r) Any other Health problems/diseases please specify
6. Has the person proposed for insurance
a) Undergone any medical test?
b) Prescribed any medicines? If yes
1. Name the illness for which medicines have been prescribed
2. Details of medicines and drugs prescribed
3. Period for which these drugs were taken
c) Been advised for any surgery/treatment? – If yes, give details
d) Received / received any payment for any disability / injury / illness / diseases. Give details
7. Does the person proposed for insurance has any of the mentioned habits
a) Chew Tobacco - If yes, since when
b) Smoke - If yes, since when
c) Consume Alcohol - If yes, since when
d) If a, b and c, are mentioned as yes, mandatory to give details whether diagnosed with any local
or systemic disease / complications.
8. Is the person proposed for insurance positive for HIV, Hepatitis B/C If yes, mention duration/date of
diagnosis, medication details, CD4 count (please attach proof) and Viral load
9. Type and the total number of medical documents provided
Applicable for STAR WOMEN CARE INSURANCE POLICY (Specific Questions for Female)
A) Is the person proposed for insurance presently pregnant? (If Yes, please submit the scan reports c Yes / c No c Yes / c No c Yes / c No c Yes / c No c Yes / c No
taken during 12th and 20th week of Pregnencry period, at Star Health specified scan centres and
mention the expected date of delivery). Applicable for Female Insured Persons
B) Any complaint of Diabetes, Hypertension or any complication during current or earlier pregnancy?
C) Has the person proposed for insurance ever undergone hysterectomy or ever had any disease of
uterus, cervix or ovaries?

Declaration of the Agent / Intermediary : I / We confirm that the product‘s suitability has been explained to
the proposer. The information furnished in the proposal is true to the best of my knowledge and
recommend acceptance of the proposal. (Please Enclose Insurance Agent’s Confidential Report, If Any) Name of the Agent / Specified Person of Signature of the Agent / Specified Person of
Date Code Corporate Agent / Broker Qualified Person / Corporate Agent / Broker Qualified Person /
Insurance Sales Person of the IMF Insurance Sales Person of the IMF
Common Proposal Form 2 3 of 4
 Proposal Form No.:
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
Acknowledgement
Received the proposal for ___________________________________________________________________________________________ policy from Mr/ Mrs/ Ms.__________________________________________________________________ along with
payment of Rs._________________/- by Cash / vide Cheque/ DD No. ___________________________dt._________________________ drawn on _____________________________. The Cash/Cheque given by you is banked for operational convenience
and banking of the Cash/Cheque does not mean acceptance of risk by us. The receipt of the Cash/Cheque will also be acknowledged by our office vide collection receipt. If the proposal is accepted, the cover will commence from the policy start date as stated in
the policy schedule, subject to realization of the Cheque. If the proposal is not accepted, the amount paid will be refunded. Contact our office, in case policy is not received within 15 days from the date of payment of premium.
Date: Place: Name & Code of the authorised person: Signature of the authorised person:

Common Proposal Form 2 4 of 4

Please affix
Please affix Please affix Please affix Please affix
stamp size
stamp size stamp size stamp size stamp size
photograph
photograph photograph photograph photograph
of Insured
of Insured of Insured of Insured of Insured
Person - 1
Person - 2 Person - 3 Person - 4 Person - 5

Submitted the above proposal for _____________________________________________________________________________ policy along with payment of Rs._______________________________ by cash/vide cheque/DD no.________________________

dated ______________________________ drawn on ____________________. I understand that the cash/cheque given is banked for operational convenience and commencement of risk is subject to the acceptance of proposal by you.

Declaration
The primary duty of the proposer is to fill out the proposal form and also to make sure that the proposal contains all the details correctly. If you or any of the insured person(s) have suffered or suffering from any of the diseases which has not been mentioned in
the proposal, the claim that may arise will result in a repudiation of the claim/cancellation of the policy.
I/we agree that the PAN details and other information provided by me/us in the proposal form may be used by the Company to download/ verify / modify / add my/our KYC documents from the CERSAI* CKYC portal for processing this application. I/We understand that only
the acceptable officially valid documents would be relied upon for processing this application. (*Central Registry of Securitization and Asset Reconstruction and security Interest of India) I hereby consent to receiving information from Central KYC Registry through SMS /
email on the above registered number/email address.
1. I 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 am authorized to propose on behalf of these
other persons. 2. 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 the insurer and that the policy will come into force only after full payment of the premium chargeable. 3. I further
declare that I 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. 4. I declare that I consent to the company
seeking medical information from any doctor or from a hospital who/which at anytime has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer
and seeking information from any insurer to whom an application for insurance on the person to be insured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement. 5. I authorize the company to share information pertaining to my
proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and /or claims settlement and with any Governmental and/or Regulatory authority. I confirm that the payment is made through my card / bank account. I also
confirm that the source of funds for premium paid under this policy is legal. I hereby confirm that the features of the product have been understood by me. I hereby authorize Star Health and Allied Insurance Company to contact me. It will override my registry on the NCPR.

Place Date Name

Signature / Thumb
impression of the
proposer:

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
LANGUAGE OF THE PROPOSAL FORM. the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
have fully understood the significance of the an inducement to any person to take out or renew or continue an
I hereby confirm that the details have been explained to the proposer. insurance in respect of any kind of risk relating to lives or property in
proposed contract.
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
prospectuses or tables of the insurer.

Date Name of the person who explained Signature of the person who explained Signature / Thumb impression of the proposer 2. Any person making default in complying with the provisions of this
section shall be liable for a penalty which may extend to ten lakh rupees.

Beware of spurious phone calls and fictitious/fraudulent offers and never respond to calls/emails/embedded links in SMS/emails asking you to update User id/Password/Credit Card Number/CVV/OTP etc.
Insurance is a contract of the utmost good faith, requiring the insured to answer all of the questions on the proposal form honestly and without omitting any information that is relevant. When submitting the proposal form, kindly reveal all pertinent information. If any important
information is omitted from the proposal form, personal statement, declaration, or related papers, or if the proposer or someone acting on his behalf makes any false or erroneous statements, misrepresentations, or omissions, the Policy will be invalid, at the insurer's
discretion. Please get in touch with the company's offices or agents if you have any questions about the proposal form.

Common Proposal Form 2 - Unique Reference No.: SHAI/PR0069

Policy Term Opted
Please choose the
through insurance repository
to the proposed insurance policy
policy and all the information related
I would like to receive my insurance
enclosed duly specifying the % to each nominee)
(Incase of Multiple nominees a separate form containing nominee details should be Do you wish to receive the copy of the policy document by Email /

Nomination

support of ID and Address††

Please attach any one proof in

Current Address District

the KYC details provided here

Do you wish to update CKYC with
CKYC Number

GST Number
Income (in Rs.)
Annual

Business Type

Date of Birth
Name
Mother
Name
Father / Spouse
(same as KYC/ID proof)
Proposer Name
Source of Income

* “Social Sector” includes unorganised sector, informal sector, economically Vulnerable or backward classes and other categories of persons, both in rural and urban areas; (a) “Unorganised sector” includes self-
†
The copy of PAN card or Form 60 is mandatory | If CKYC number is provided, proof of submission is not mandatory | Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with

repair and maintenance, construction, personal and domestic services and manufacturing, with the work mostly labour intensive, having often unwritten and informal employer-employee relationship.
small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of generating employment and income, with heterogeneous activities like retail trade, transport,
Rights and Full Participation) Act, 1995 and who may not be gainfully employed; and also includes guardians who need insurance to protect spastic persons or persons with disability. (d) “Informal Sector” includes
Backward Classes” means persons who live below the poverty line. (c) “Other Categories of Persons” includes persons with disability as defined in the Persons with Disabilities (Equal Opportunities, Protection of
cutters, tendu leaf collectors, toddy tappers, vegetable vendors, washerwomen, working women in hills, daily wagers, hired drivers and coolies or such other categories of persons.(b)“Economically Vulnerable or
and tannery workers, papad makers, powerloom workers, physically handicapped self-employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane
employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers, fishermen, hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather
Premium can also be paid: Annually for 1 year term /
prominent public functions in a foreign country, example, Heads of State or of Governments, senior politicians, senior government / judicial / military officials, senior executives of state owned corporations,

Biennial for 2 year term / Triennial for 3 years

:
Village
City / Town /
Number
Mobile
Pincode
Country and
State

Address line 2

Address line 1
(if nominee is a minor) :
Name of the Appointee
Nominee’s Name :

(please

Prefix
If Yes
tick)

Policy Issuing Office

Salaried
1 yr

D
Do you come under below mentioned Social Sector Classification*

M
Regd. & Corporate Office : 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034. | Phone : 044 - 28288800
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Other Categories of Persons

Unorganized Sector

Policy No.: ________________________________________________

Ref. No.: __________________________________________________

M
2 yrs
Email : [email protected] | Website : www.starhealth.in | CIN : L66010TN2005PLC056649 | IRDAI Regn. No. : 129

Yes

Business
Voter

Y
††

Yes
No

ID

First Name
3 yrs Period of
(Please check the brochure for policy term and Instalment facility in respect of each product)

Account (eIA) number, please provide:

If you already have an e-Insurance If you don’t have an
important political party officials, etc., including their family members and close relatives.

PAN Number†
No PEP

Y
premium in Instalments
Do you want to pay the
Insurance

Exp
Driving License

Are you (Proposer) or any of the insured person is†††a

please specify ______________ to be submitted

Others,

PROPOSER DETAILS
Dt.:

(Politically Exposed Person) or related to PEP

Gender
From

IMF / NAME
AGENT / BROKER /
CORPORATE
AGENT /
IMF / CODE
AGENT / BROKER /
CORPORATE
AGENT /
SM NAME

SM CODE
Informal Sector

Economically Vulnerable or Backward Classes

to Nominee :
Relationship
to
Relationship
Proposer
D

Male
Aadhar
D M M

Card
:

Proof of Income
Yes

Whatsapp / Any other electronic mode

Permanent
(should be
Address
same as
address
Proof)
Insurance Repository
choose any one
(elA) number, please

Email ID

Middle Name
Female
Exp
Passport
No
†††

Residential Status
Y

PRO / COMMON 2 / V.1 / 2022

Dt.:
Birth
Date of
Birth
Date of

Mobile Number
Alternate
Pincode
Country and
State

District
Village
City / Town /
Address line 2

Address line 1

Yes
Y
If yes (Please choose
Instalment option)

The company will not be on risk until the proposal has been
Returns

Transgender
Y

accepted and full payment of premium has been received.

IT
Yes

PLEASE FILL UP THE FORM IN BLOCK LETTERS

No
D

D
Y
Repository Limited
CDSL Insurance
Repository Limited
Karvy Insurance

If PAN number is not available submit Form 60†

D M M

D M M

Are you a MGNREGA worker

To

Are you a ASHA worker

Job

Resident
No provide
NREGA

Payslip
3mths
Indian

Occupation
Rural and Social Sector Classification
Card

If yes, please

Proposal Form No.:

D D M M

details________________________
Quarterly

please specify_______________
Other Proof,
Document
Any Other Govt. Notified

NRI
Y

Last Name
Repository (NIR)
NSDL National Insurance
Services Limited
CAMS Insurance Repository

of the Proposer

Passport size
Please affix
photograph
PIO
Y

Y Age

Y Age
Yes

Yes

Yes
Y
Halfyearly

National
Foreign
Y

1 of 4
yrs

yrs
No

No

No
in

in
Y