st

1 Floor, Tradeview, Oasis Complex, Kamala City,

P. B. Marg, Lower Parel (W). Mumbai - 400013.
Toll Free: 1800 22 1120 (For MTNL subscribers),
1800 102 5005 (For non-MTNL subscribers).
E-mail: support@idbifortis.com, www.idbifortis.com Application No.:

310203745
Healthsurance
IDBI Fortis Healthsurance Hospitalisation and Surgical Plan
UIN: 135N012V01

PROPOSAL FORM
DM
Proposal Number Application Receipt Date
Photo of
Client ID Number Acknowledgement No. premium payer
Manager Code / Agent Code 1000016347
Distributor Code IDBI Bank ✔ Federal Bank IDBI Fortis
for premium
General instructions & warnings: above
Please complete all sections of this Proposal Form in full, using capital letters, and answer all questions truthfully and honestly by making a full
and frank disclosure of all material facts. If a full and frank disclosure is not made of all material facts, or if any material fact is misrepresented, IDBI
Rs 10,000.
Fortis has the right to treat any policy that may be granted as void from the start. Make sure you have read and understood the Declarations and
Authorisation under PART 6 of this form, before signing and returning it together with all other required documents. All corrections made in the
proposal form must be countersigned by the proposer. Nomination facility is available under Part 2. Please use this facility.

PART-I: DETAILS OF PERSON TO BE INSURED (To be filled in block letters)

1. Full name LUMINAMMA MATHEW
2. Date of Birth 05/05/1958 3. Gender Male ✔ Female
4. Marital Status Married Single Widow(er) Divorcee
5. Mailing Address THENGUMPALLIL, CMC 19 ,CHERTHALA, CHERTHALA, ALAPPUZHA.,KERALA, INDIA, LM:STOP GREEN GAARDEN HOSPITAL OPP ROAD.,
9447568444 PIN 688524
State Kerala Nationality
6. Permanent address THENGUMPALLIL, CMC 19 ,CHERTHALA, CHERTHALA, KERALA, INDIA, 688524
(only if different from PIN 688524
address above)
State Kerala Nationality
7. Tel (With STD Code) 04782814513 Mobile 04782814513
8. Occupation
9. Annual Income (only if Rs. 0
proof of income is required)

PART-II: DETAILS OF NOMINEE

As per section 39 of the Insurance Act, 1938, you can nominate one or more persons (“nominees”) to receive any benefit payable under this policy in the unfortunate
event of your death. Please give details of the nominee. If you wish to have more than one nominee, please give details on a separate sheet of paper and show
percentage share of benefit to be paid to each nominee.
You should also name an appointee for any nominee who is aged under 18 years of age. Any appointee must be aged 18 years or more.

Name of the Nominee Relationship to you Date of Birth Address and contact number

Appointee (required only if nominee is below 18 years)

Name of the Nominee Relationship to you Date of Birth Address and contact number

PART-III: PLAN AND PAYMENT DETAILS

Confirm the cover you have selected
(tick one box only)
✔
1. Daily Hospital Cash Benefit (Rs) 500 1,000 1,500 2,000 3,000* 4,000*
2. Monthly Premium
(including service tax and
education CESS) –
644
3. Payment mode ✔ Monthly Annually
4. Payment method ✔ ECS S.I# Cheque (annual payments only) IVR Payment
5. Bank Account number
(ECS and SI only)#
6. Bank and branch name
(ECS and SI only)
#
Standing instruction is available only if the proposer has an account with IDBI Bank or Federal Bank.

PART-IV: FIRST TWO MONTHS' PREMIUMS

You must pay your first two months' premiums by cheque, if you choose the monthly payment mode. Please give details of your cheque payment below:
Cheque number
MICR code

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 PART-V: ADDITIONAL MANDATORY INFORMATION
A) Indicate the type of identification proof submitted (Any one)
Passport Voter's card Employer Certificate Advisor License Armed forces ID card Pan card
Letter from recognised public authority or public servant verifying the identity Valid Driving License
Trade/Professional license where photo and signature is available Bank verification
Credit card with photo and signature ID card issued by public authority
Others (includes documents as decided by the company with approval of compliance from time to time): _________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
B) Indicate the type of residential proof submitted (Any one) All residential proof (except Premium receipt) must be not more than 6 months old
Telephone / Mobile bill Letter from recognised public authority Deeds to property Ration card
Lease agreement (including last 3 months rent receipts) Valid Driving License
Premium payment notice / receipt of insurance companies (of last 1 year) Bank verification
Passport Bank account statement Bank / Post office saving passbook Bank verification
Voter's card Electricity bill Valid Driving License Employer letter
Others (includes documents as decided by the company with approval of compliance from time to time): _________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
C) Indicate the type of income proof submitted (if required) (Any one) Income proof is mandatory if the Daily Hospital Cash benefit you have chosen is Rs 3,000 or Rs 4,000
Form 16 income tax assessment order / ITR (for self employed last 2 years) Employer's certificate (with salary break up)
Audited firm accounts and partnership (last 2 years) Chartered Accountant's certificate
Agricultural income certificate Agricultural land details and income assessments
Bank cash flow statement (not more than 6 months old) Audited company accounts (last 2 years)
Salary slip (Latest month for regular income employees, 3 months for commission income employees) (electronic also accepted)
Others (includes documents as decided by the company with approval of compliance from time to time): _________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

PART-VI: IMPORTANT QUESTIONS

Please answer the following questions truthfully by ticking “Yes” or “No” Yes No
1. Has any application of yours for life, accident or health insurance been declined, postponed or accepted at other than standard terms? ✔

2. Do you take or need to take medications on a regular basis, or are you currently having or awaiting any form of ongoing medical ✔

treatment, consultations or investigations or the results from any medical test or investigation, or have you been advised to undergo
any medical tests, investigations or surgery?
3. In the last 5 years, have you had any condition which required you to take medication for longer than 10 consecutive days or have you ✔
been absent from work for health reasons for longer than 5 consecutive days?
4. In the last 5 years, have you suffered from or had advice, referral or tests for any major, chronic or long-term disease such as heart ✔

disease, stroke, cancer, hepatitis, diabetes, high blood pressure, raised cholesterol requiring treatment, mental illness, lung, kidney
or bowel disease or similar conditions?
5. Do you work, either part-time or full-time, in any of the following conditions, occupations or professions:
Working in confined spaces in vessels, tunnels, underground civil works, mines, rigs.(including offshore rigs) or ships, ✔

Industrial work using heavy machinery, or working as a welder ✔

Working in the agricultural sector, as a forestry worker or as timber camp personnel ✔

Working with toxic chemicals or explosives or in weapons manufacture or trading or in the demolition trade, ✔

Working in transport business (unless only doing clerical work) ✔

Working at heights (at least 20 metres above the ground or floor level) ✔

Working as a fireman, security guard or patrolman, or as a member of the police force or serving in the armed forces. ✔

PART-VII: DECLARATION & AUTHORISATION

I declare and warrant on my behalf that the answers given in response to the questions above, and the
statements made in this proposal or otherwise in support of this application are true, correct and complete in
all respects, and there is no other information material to the application that has not been disclosed.
I understand that the statements made under this proposal and this declaration will be the basis of contract of
assurance between me and IDBI Fortis and that if any statement is untrue or inaccurate, or if any fact that might
influence the terms of acceptance of this proposal is not disclosed, the contract shall be treated as null and void
from the start and all premiums so far paid in respect of this contract shall stand forfeited subject to law.
And I further agree that if, after the date of submission of the proposal but before the issue of policy, (i) any
change in my occupation or any adverse circumstances connected with my financial position or the general
health of myself occurs or (ii) if a proposal for assurance or an application for revival of a policy on my life or
made to any insurer is withdrawn or dropped, deferred, declined or accepted at an increased premium or
subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to IDBI Fortis in
writing. Any omission on my part to do so shall render this assurance invalid and all monies which shall have
Signature/thumb impression of the person
to be insured
been paid in respect thereof shall stand forfeited to IDBI Fortis.
I declare that I have been briefed on the product features and benefits and that I have fully understood the
contents of this proposal, the significance of the proposed policy and the product before filling this proposal
form.
I agree that the policy shall not commence till IDBI Fortis accepts and underwrites this proposal and
communicates to me the commencement of the policy.
FREE LOOK PERIOD:
I understand that I have the right to cancel my policy by giving written notice signed by me along with the
policy document within 15 days from the date of receipt of the policy and obtain refund of the premium paid,
subject only to the deduction of expenses incurred by IDBI Fortis on stamp duty charges.
Signature of advisor or specified person
from the Corporate Agent/Broker

Place: _____________________________ Place: ______________________________

Date: ______________________________ Date: ______________________________

PART-VIII: DECLARATION TO BE GIVEN IF PROPOSAL IS SIGNED IN THE VERNACULAR

(or if the person to be insured has used a thumb impression instead of a signature)
I,_________________________________________________________ (name) have explained the contents of this proposal to the________________________________(Proposer) in _______________________________ (language)
and ensured that the contents have been fully understood by him/her. I have accurately recorded the Proposer's responses to the information sought in the proposal form and I have read out the responses to the Proposer and
he/she has confirmed that they are correct.

Signature of the person making the declaration: _________________________________________________ Place: _______________________________________________ Date: __________________________________
Address of the person making the declaration: _____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________

Sections 41 and 45 of The Insurance Act, 1938

SECTION 41 OF THE INSURANCE ACT, 1938: "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 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 published prospectus or tables of Insurer."
SECTION 45 OF THE INSURANCE ACT, 1938: “No policy of life insurance effected before the commencement of this Act
shall, after the expiry of two years from the date of commencement of this Act, and no policy of life insurance effected
after the coming into force of this Act shall, after the expiry of two years from the date on which it was effected, be called
into question by an Insurer on the grounds that a statement made in the proposal for insurance or any report of medical
officer, or referee, or friend of the insured, or in any other document leading to issue of policy was inaccurate or false,
unless the Insurer shows that such statement was on a material matter or suppressed fact which it was material to disclose
and that it was fraudulently made by the policy-holder and that the policy-holder knew at the time of making it that the
statement was false or that it suppressed facts which it was material to disclose. Provided that nothing in this section shall
prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be
called in question merely because the terms of the policy are adjusted on subsequent proof that the age of life insured was
incorrectly stated in the proposal.”

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