Proposal Form No.: Proposal Form No.

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

the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
policy along with payment of Rs._______________________________ by cash/vide cheque/DD no.________________________

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

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.
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.
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
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 date of the collection receipt, subject to realization of the Cheque. If the proposal is not accepted, the amount paid Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai - 600 034. « Phone : 044 - 28288800 « Email : [email protected]
Website : www.starhealth.in « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129

The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
Please affix

photograph

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.
stamp size

Person - 5
of Insured
STAR WOMEN CARE INSURANCE POLICY Ref. No. The company will not be on risk until the proposal has
Unique Identification No.: SHAHLIP23132V022223 been accepted and full payment of premium has been
Proposal Form - Unique Reference No.: SHAI/PR0069 Policy No. received. Please fill up the form in block letters.

prospectuses or tables of the insurer.

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.
Policy Issuing Office: SM CODE SM NAME
AGENT / AGENT /
CORPORATE CORPORATE
AGENT / AGENT /
authorised person:

BROKER / BROKER /
Signature of the

IMF / CODE IMF / NAME

Name of the Proposer Annual
Rs.
Mr / Mrs / Ms. Income

Signature / Thumb
Occupation of the Proposer Date of Birth DD/MM/YYYY

impression of the
Please affix

photograph
stamp size

Person - 4
of Insured

Residential Address: Office Address:

have fully understood the significance of the

proposer:
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Pin Code: Pin Code:

Signature / Thumb impression of the proposer

Mobile No. Email ID

PAN Number GST Number

Do you have a CKYC number c Yes c No If yes Please mention the number
Do you come under below mentioned Social Sector Classification*: q Yes q No Rural and Social Sector Classification
BUSINESS If Yes : q a. Unorganized Sector q b. Economically Vulnerable or Backward Classes Are you a ASHA workers q Yes q No

proposed contract.
TYPE
Acknowledgement

q c. Other Categories of Persons q d. Informal Sector Are you a MGNREGA workers q Yes q No
* “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-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers, fishermen,
Declaration
Please affix

photograph
stamp size

Person - 3
of Insured

hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather and tannery workers, papad makers, powerloom workers, physically handicapped self-
employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane 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.
Name

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE LANGUAGE
b. “Economically Vulnerable or 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 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.

Signature of the person who explained

Name & Code of the

d. “Informal Sector” includes small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of generating employment
authorised person:

and income, with heterogeneous activities like retail trade, transport, repair and maintenance, construction, personal and domestic services and manufacturing, with the
work mostly labour intensive, having often unwritten and informal employer-employee relationship.

NOMINATION
Nominee’s Relationship
will be refunded. Contact our office, in case policy is not received within 15 days from the date of payment of premium.

Date of Birth DD/MM/YYYY Age Yrs

Name to Proposer
STAR WOMEN CARE INSURANCE POLICY

Name of the Appointee Relationship

Date of Birth DD/MM/YYYY Age Yrs
(if nominee is a minor) to Nominee
I hereby confirm that the details have been explained to the proposer.

(Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee)
Policy Term (Please P) c 1 Year / c 2 Years / c 3 Years Period of Insurance From To
Please affix

photograph

Do you wish to receive the copy of the policy document by Email / Whatsapp /
stamp size

Person - 2

■ YES ■ NO ■ YES ■ NO
of Insured

Do you want to pay the premium in Instalments

Any other electronic mode
If yes choose Instalment options (Please Select the Option) c Quarterly c Halfyearly Type of Policy Opted c Individual c Floater
Date

Please check brochure for Instalment facility Premium can also be paid: Annually for 1 year term / Biennial for 2 year term / Triennial for 3 years
Sum Insured Opted (Please tick the required sum c5 c 10 c 15 c 20 c 25 c 50
STAR WOMEN CARE INSURANCE POLICY

c 100 Lakhs
insured in Rs.) Applicable for Floater Type Policy Lakhs Lakhs Lakhs Lakhs Lakhs Lakhs
Name of the person who explained

Family Size (Please tick the required family size)

c 1A+1C c 1A+2C c 1A+3C c 2A c 2A+1C c 2A+2C c 2A+3C
Applicable for Floater Type Policy
I would like to receive my insurance policy and all the information related to Do you wish to receive the physical
the proposed insurance policy through insurance repository YES ■ NO ■ copy of the policy document YES ■ NO ■
If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number:_____________________________________________________
Place:

If you don’t have an (elA) number, choose any one n CAMS Insurance Repository Services Limited n CDSL Insurance Repository Limited
Submitted the above proposal for

Insurance Repository n Karvy Insurance Repository Limited n NSDL National Insurance Repository (NIR)
Bank Details Account Number
Please affix

Type of Account : q SB q CA q Others please specify ______________

photograph
stamp size

Person - 1
of Insured

Place

OF THE PROPOSAL FORM.

of the
Proposer Name of the IFSC
Name of the Bank
Branch Code
Please attach a photo copy of cancelled cheque leaf of the above Bank Account.
Payments
Received the proposal for

Premium Amount Rs. Mode of Payment : Cash / Cheque / DD / Credit Card / Debit Card / NEFT / CC Mandate / ECS
Details
Date

Cheque / Drawn
Date Branch
DD No. on
Please attach any one proof of Date of Birth : q Birth Certificate q Voter ID q PAN Card q Driving License q Aadhar Card q Any other Govt. Recognised Proof

Star Women Care Insurance Policy 4 of 4 Star Women Care Insurance Policy PRO / SWC / V.4 / 2022 1 of 4
Date:
Star Women Care Insurance Policy

Details of the person 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 / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY

Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS CMS KGS

Occupation Annual Income (Rs.)

Sum Insured Opted (Applicable Individual Type Policy)

Do you want optional Cover (Applicable only for Females) c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No

If yes, Please mention Sum Insured Opted for Optional Cover

Relationship with proposer

1. Name of the Insurance Company

Existing
Insurance
Coverage 2. Period of Insurance
with this
company and
any other 3. Sum Insured (Rs)
company -
give details
4. Policy No.

1. Ailment for which

Details Year YYYY YYYY YYYY YYYY YYYY
Claim was made
of
Claims 2. Claim Amount Paid / Rejected

Health History :Please provide answer in detail.

A mere dash is not sufficient.
Family Physician's Name:_____________________________________________Phone:____________________________________________Regn No:____________________________________
1. Specific Questions for Female

a. Is the person proposed for insurance presently pregnant? (If Yes, please submit the
scan reports 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?
2. Is the person proposed for insurance in good health free from physical and mental
disease or infirmity. If not give details
3. Has the person proposed for insurance consulted/ diagnosed /taken treatment /been
admitted for any illness/injury. If Yes, give details
4. Does the person proposed for insurance have any complications during / following
birth. If yes, please submit all necessary documents.
5. Has the person proposed for insurance ever suffered or suffering from any of the following
2 of 4

a) Diabetes Mellitus - If Yes, since when

b) High BP, Cholesterol - If Yes, since when

c) Heart Disease - If Yes, since when

Star Women Care Insurance Policy

d) Stroke, epilepsy, fainting attack, chronic headache, Parkinson's disease,

Alzheimer's disease, - If Yes since when

e) Tuberculosis, asthma, other respiratory infections - If Yes, since when

f) Disease of bones/joints, slipped disc, spinal disorder, injury to ligaments - If Yes,

since when

g) Cancer, Pre Cancerous Lesion - If Yes, since when

h) Gynecological disorder such as DUB, Fibroid Uterus, Ovarian cyst - or have

undergone cesarean / Hysterectomy If Yes, since when
i) Treatment for sub fertility or has been advised for? (answer if applicable) – If Yes
provide details.
j) Disease of Stomach, Intestine, Liver, Gall bladder / Pancreas, Kidney, Urinary
bladder, Urinary Tract Diseases - If Yes, since when

k) Disease of Prostrate / Fistula / Piles / Genital diseases - If Yes, since when

l) Cataract and other diseases of the eye and ENT disease - If Yes since when

m) Any Other Problem (Please Specify)

6. Has the person/s proposed for insurance
a) Undergone any medical test?
b) Prescribed any medicines? If yes
i) Name the illness for which medicines have been prescribed
ii) Details of medicines and drugs prescribed.

iii) Period for which these drugs were taken.

c) Been advised for any surgery / treatment ? - If Yes, give details

d) Received / receiving any payment for any disability / injury / illness/ disease.
Give details

7. Does the a) Chew Tobacco - If Yes, since when

person
proposed b) Smoke - If Yes, since when
for
insurance c) Consume Alcohol - If Yes, since when
8. Is the person proposed for insurance positive for HIV If yes, please mention your
CD4count (Please attach proof)

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 Corporate Agent / Signature of the Agent / Specified Person of Corporate Agent /
Code
3 of 4

Broker Qualified Person / Insurance Sales Person of the IMF Broker Qualified Person / Insurance Sales Person of the IMF
Star Women Care Insurance Policy

Details of the person 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 / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY M / F / Thirdgender DD/MM/YYYY

Height (cms) Weight (kgs) CMS KGS CMS KGS CMS KGS CMS KGS CMS KGS

Occupation Annual Income (Rs.)

Sum Insured Opted (Applicable Individual Type Policy)

Do you want optional Cover (Applicable only for Females) c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No

If yes, Please mention Sum Insured Opted for Optional Cover

Relationship with proposer

1. Name of the Insurance Company

Existing
Insurance
Coverage 2. Period of Insurance
with this
company and
any other 3. Sum Insured (Rs)
company -
give details
4. Policy No.

1. Ailment for which

Details Year YYYY YYYY YYYY YYYY YYYY
Claim was made
of
Claims 2. Claim Amount Paid / Rejected

Health History :Please provide answer in detail.

A mere dash is not sufficient.
Family Physician's Name:_____________________________________________Phone:____________________________________________Regn No:____________________________________
1. Specific Questions for Female

a. Is the person proposed for insurance presently pregnant? (If Yes, please submit the
scan reports 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?
2. Is the person proposed for insurance in good health free from physical and mental
disease or infirmity. If not give details
3. Has the person proposed for insurance consulted/ diagnosed /taken treatment /been
admitted for any illness/injury. If Yes, give details
4. Does the person proposed for insurance have any complications during / following
birth. If yes, please submit all necessary documents.
5. Has the person proposed for insurance ever suffered or suffering from any of the following
2 of 4

a) Diabetes Mellitus - If Yes, since when

b) High BP, Cholesterol - If Yes, since when

c) Heart Disease - If Yes, since when

Star Women Care Insurance Policy

d) Stroke, epilepsy, fainting attack, chronic headache, Parkinson's disease,

Alzheimer's disease, - If Yes since when

e) Tuberculosis, asthma, other respiratory infections - If Yes, since when

f) Disease of bones/joints, slipped disc, spinal disorder, injury to ligaments - If Yes,

since when

g) Cancer, Pre Cancerous Lesion - If Yes, since when

h) Gynecological disorder such as DUB, Fibroid Uterus, Ovarian cyst - or have

undergone cesarean / Hysterectomy If Yes, since when
i) Treatment for sub fertility or has been advised for? (answer if applicable) – If Yes
provide details.
j) Disease of Stomach, Intestine, Liver, Gall bladder / Pancreas, Kidney, Urinary
bladder, Urinary Tract Diseases - If Yes, since when

k) Disease of Prostrate / Fistula / Piles / Genital diseases - If Yes, since when

l) Cataract and other diseases of the eye and ENT disease - If Yes since when

m) Any Other Problem (Please Specify)

6. Has the person/s proposed for insurance
a) Undergone any medical test?
b) Prescribed any medicines? If yes
i) Name the illness for which medicines have been prescribed
ii) Details of medicines and drugs prescribed.

iii) Period for which these drugs were taken.

c) Been advised for any surgery / treatment ? - If Yes, give details

d) Received / receiving any payment for any disability / injury / illness/ disease.
Give details

7. Does the a) Chew Tobacco - If Yes, since when

person
proposed b) Smoke - If Yes, since when
for
insurance c) Consume Alcohol - If Yes, since when
8. Is the person proposed for insurance positive for HIV If yes, please mention your
CD4count (Please attach proof)

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 Corporate Agent / Signature of the Agent / Specified Person of Corporate Agent /
Code
3 of 4

Broker Qualified Person / Insurance Sales Person of the IMF Broker Qualified Person / Insurance Sales Person of the IMF
Proposal Form No.: Proposal Form No.:
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

the product have been fully explained to me and I 1. No person shall allow or offer to allow, either directly or indirectly, as
policy along with payment of Rs._______________________________ by cash/vide cheque/DD no.________________________

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

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.

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

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 date of the collection receipt, subject to realization of the Cheque. If the proposal is not accepted, the amount paid

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai - 600 034. « Phone : 044 - 28288800 « Email : [email protected]
Website : www.starhealth.in « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129
The contents of the proposal form and features of Prohibition of Rebates: Section 41 of Insurance Act 1938.
Please affix

photograph

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.
stamp size

Person - 5
of Insured

STAR WOMEN CARE INSURANCE POLICY Ref. No. The company will not be on risk until the proposal has
Unique Identification No.: SHAHLIP22217V012122 been accepted and full payment of premium has been
Proposal Form - Unique Reference No.: SHAI/PR0069 Policy No. received. Please fill up the form in block letters.
prospectuses or tables of the insurer.
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.

Policy Issuing Office: SM CODE SM NAME

AGENT / AGENT /
CORPORATE CORPORATE
AGENT / AGENT /
authorised person:

BROKER / BROKER /
Signature of the

IMF / CODE IMF / NAME

Name of the Proposer Annual
Rs.
Mrs / Ms. Income
Signature / Thumb

Occupation of the Proposer Date of Birth DD/MM/YYYY

impression of the
Please affix

photograph
stamp size

Person - 4
of Insured

Residential Address: Office Address:

have fully understood the significance of the
proposer:
STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Signature / Thumb impression of the proposer Pin Code: Pin Code:

Mobile No. Email ID
PAN Number GST Number
Do you have a CKYC number c Yes c No If yes Please mention the number
Do you come under below mentioned Social Sector Classification*: q Yes q No Rural and Social Sector Classification
BUSINESS If Yes : q a. Unorganized Sector q b. Economically Vulnerable or Backward Classes Are you a ASHA workers q Yes q No

proposed contract.
TYPE
Acknowledgement

q c. Other Categories of Persons q d. Informal Sector Are you a MGNREGA workers q Yes q No
* “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-employed workers such as agricultural labourers, bidi workers, brick kiln workers, carpenters, cobblers, construction workers, fishermen,
Declaration
Please affix

photograph
stamp size

Person - 3
of Insured

hamals, handicraft artisans, handloom and khadi workers, lady tailors, leather and tannery workers, papad makers, powerloom workers, physically handicapped self-
employed persons, primary milk producers, rickshaw pullers, safaikarmacharis, salt growers, sericulture workers, sugarcane 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.
Name

WHERE THE PROPOSER IS ILLITERATE OR SIGNS IN A LANGUAGE DIFFERENT FROM THAT OF THE LANGUAGE
b. “Economically Vulnerable or 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 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.

Signature of the person who explained

Name & Code of the

d. “Informal Sector” includes small scale, self-employed workers typically at a low level of organisation and technology, with the primary objective of generating employment
authorised person:

and income, with heterogeneous activities like retail trade, transport, repair and maintenance, construction, personal and domestic services and manufacturing, with the
work mostly labour intensive, having often unwritten and informal employer-employee relationship.

NOMINATION
Nominee’s Relationship
will be refunded. Contact our office, in case policy is not received within 15 days from the date of payment of premium.

Date of Birth DD/MM/YYYY Age Yrs

Name to Proposer
STAR WOMEN CARE INSURANCE POLICY
Name of the Appointee Relationship
Date of Birth DD/MM/YYYY Age Yrs
(if nominee is a minor) to Nominee

I hereby confirm that the details have been explained to the proposer.
(Incase of Multiple nominees a separate form containing nominee details should be enclosed duly specifying the % to each nominee)
Policy Term (Please P) c 1 Year / c 2 Years / c 3 Years Period of Insurance From To
Please affix

photograph

Do you wish to receive the copy of the policy document by Email / Whatsapp /
stamp size

Person - 2

■ YES ■ NO ■ YES ■ NO
of Insured

Do you want to pay the premium in Instalments

Any other electronic mode
If yes choose Instalment options (Please Select the Option) c Quarterly c Halfyearly Type of Policy Opted c Individual c Floater

Date
Please check brochure for Instalment facility Premium can also be paid: Annually for 1 year term / Biennial for 2 year term / Triennial for 3 years
Sum Insured Opted (Please tick the required sum c5 c 10 c 15 c 20 c 25 c 50
STAR WOMEN CARE INSURANCE POLICY

c 100 Lakhs
insured in Rs.) Applicable for Floater Type Policy Lakhs Lakhs Lakhs Lakhs Lakhs Lakhs

Name of the person who explained

Family Size (Please tick the required family size)
c 1A+1C c 1A+2C c 1A+3C c 2A c 2A+1C c 2A+2C c 2A+3C
Applicable for Floater Type Policy
I would like to receive my insurance policy and all the information related to Do you wish to receive the physical
the proposed insurance policy through insurance repository YES ■ NO ■ copy of the policy document YES ■ NO ■
If you already have an e-Insurance Account (eIA) number, kindly provide e-Insurance Account (eIA) number:_____________________________________________________
Place:

If you don’t have an (elA) number, choose any one n CAMS Insurance Repository Services Limited n CDSL Insurance Repository Limited

Submitted the above proposal for

Insurance Repository n Karvy Insurance Repository Limited n NSDL National Insurance Repository (NIR)
Bank Details Account Number

Please affix
Type of Account : q SB q CA q Others please specify ______________

photograph
stamp size

Person - 1
of Insured

Place

OF THE PROPOSAL FORM.

of the
Proposer Name of the IFSC
Name of the Bank
Branch Code
Please attach a photo copy of cancelled cheque leaf of the above Bank Account.
Payments
Received the proposal for

Premium Amount Rs. Mode of Payment : Cash / Cheque / DD / Credit Card / Debit Card / NEFT / CC Mandate / ECS
Details

Date
Cheque / Drawn
Date Branch
DD No. on
Please attach any one proof of Date of Birth : q Birth Certificate q Voter ID q PAN Card q Driving License q Aadhar Card q Any other Govt. Recognised Proof
Star Women Care Insurance Policy 4 of 4 Star Women Care Insurance Policy PRO / SWC / V.1 / 2022 1 of 4

Date: