Proposal Form For “Oriental Bank Mediclaim” Policy

THE ORIENTAL INSURANCE COMPANY LIMITED
HEAD OFFICE: A‐25/27, ASAF ALI ROAD, NEW DELHI‐110002

“ORIENTAL BANK MEDICLAIM” POLICY
(WITH FAMILY FLOATER)
FOR THE ACCOUNT HOLDERS / EMPLOYEES OF ORIENTAL BANK OF COMMERCE
PROPOSAL FORM
1. FORM TO BE FILLED IN BLOCK LETTERS.
2. PLEASE SUBMIT TWO STAMP SIZE PHOTOGRAPHS OF EACH INSURED PERSON ALONGWITH TWO
COPIES OF PROPOSAL FORM. NAME AND AGE OF THE INSURED MUST BE WRITTEN ON THE
BACK OF THE PHOTO.
3. FAMILY TO INCLUDE THE PROPOSER i.e., ACCOUNT HOLDER/EMPLOYEE of the Oriental Bank of
Commerce (OBC). HIS/HER SPOUSE AND TWO DEPENDENT CHILDREN ( i.e. legitimate or legally
adopted children) AGED 3 COMPLETED MONTHS ONWARDS UPTO 79 YEARS AS UNDER:
• FEMALE CHILD UNTIL SHE IS MARRIED. IMMEDIATELY CONSEQUENT UPON HER
MARRIAGE SHE SHALL BE CEASED TO BE COVERED UNDER THE POLICY AND NO CLAIM
SHALL BE ADMISSIBLE.
• MALE CHILD UPTO THE AGE OF 26 YEARS IF HE IS ABONAFIDE REGULAR STUDENT AND
FULLY DEPENDENT ON PROPOSER i.e., THE OBC ACCOUNT HOLDER.
1. NAME OF THE INSURED PERSON AND RELATIONSHIP WITH THE PROPOSER. ( AGE GROUP 3
COMPLETED MONTHS TO 79 YEARS COMPLETED YEARS) – FAMILY SHALL MEAN THE INSURED
PERSON, SPOUSE AND TWO DEPENDENT CHILDREN
S.
No.
Name of the insured’s
/proposer
Relationship
with
Proposer
Sex
M/F
Date of Birth Age Occupation Sum
Insured
(Rs.)
1.
2.
3.
4.
2. ADDRESS & TELEPHONE NO. / MOBILE NO. / E‐MAIL ADDRESS
Mobile
No.
Ph.
no.
E‐mail
3. PLEASE ANSWER THE FOLLOWING IN YES / NO
ProposarSpouse Child‐1 Child ‐2
A. Are all the persons proposed for insurance in good
health and free from physical and mental diseases or
infirmity or major complaints ?
4. OBC ACCOUNT NUMBER
BRANCH :
CITY:
ACCOUNT NO :
5. PERMANENT ACCOUNT NO. OF THE PROPOSER (PAN NO.) (ISSUED BY INCOME‐ TAX
AUTHORTIES)/(Optional)
6 NAME OF THE NOMINEE IN THE EVENT OF THE DEATH OF INSURED DURING THE COURSE OF
TREATMENT.
S.NO. First Name of the Insured Name of the Beneficiary Relation
with
Insured
1.
2.
3.
4.
6. Details of existing Mediclaim Policy (If any):‐
Name of Company Sum Insured Policy Number Date of expiry
I/We declare that the statements made by me/us in this proposal form are true and to the best of my / our
knowledge and belief and I/we hereby agree that this declaration shall form the basis of the contract between
me/us and The Oriental Insurance Company Limited. I/we also declare that if any additions or alterations are
carried out after the submission of this proposal form and / or issuance of policy documents. The same would be
conveyed to the Oriental Insurance Company Limited immediately. I further consent and authorize the Oriental
Insurance Company Limited and /or any of its authorized representatives to seek medical information from any
hospital/medical practitioner who has attended or may attend in future concerning any disease or illness. I further
declare that I have read the prospectus and have understood the same. I accept the policy, subject to terms,
exceptions and conditions prescribed therein and further disclose that In the event of finding any thing contrary to
what has been declared by me, I shall be held responsible for all consequences thereof and insurance company
shall incur no liability under this insurance.
I/we also hereby authorise OBC to debit the premium payable under the policy to my/our Bank Account
Number: ______________________________________ with OBC Branch
____________________________________ at _________________________________________.
Place Signature of Proposer (OBC A/c Holder)
Date Name of Proposer
COUNTER SIGNATURE BY OBC BRANCH MANAGER
Place Signature
Date Name
BRANCH CODE, LOCATION AND CITY
INSURANCE ACT 1938 SECTION 41 – PROHIBITION OF REBATES
Section 41 of the Insurance Act 1938 provides as follows:
Any person making default in complying with provision of this section shall be punishable with fine which
may extend of Rs. 500/‐.
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 if 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 prospectus or tables
of the insurer.
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