Proposal Form For UCO Medi+Care Bima Policy

NATIONAL INSURANCE COMPANY LIMITED

UCO Medi + Care Bima Policy

PROPOSAL FORM

1) UCO Bank Branch Office:______________________ Branch Code No.____________

2) Name of the Proposer:_____________________________________________

3) SB/CA Account No. (if any):_______________________________________________

4) Postal Address and Telephone No._________________________________________
_____________________________________________________________________________________________________________________________________________

5) Name and Address of Medical Practitioner / Family Doctor: _____________________

6) Plan Opted for: (Plan A/PlanB)

7) Sum Insured per family under Hospitalization and Personal Accident cover:
Rs. 50,000 ( ) Rs.100,000 ( ) Rs.150,000 ( )
Please put a tick mark Rs.200,000 ( ) Rs.250,000 ( ) Rs.300,000 ( )
Rs. 350,000 ( ) Rs. 400,000 ( ) Rs. 450,000 ( )
Rs. 500,000 ( )

7a)Sum Insured under Hospitalization & Personal Accident cover in words: - ______________________________________________

8) Capital Sum Insured per person under Personal Accident:
(a)For Primary member: 100% of S.I. for the family under Hospialization & Personal Accident cover
(b) Spouse :50% of S.I. for the family under Hospialization & Personal Accident cover
©Each Dependant Children : 25% of S.I. for the family under Hospialization & Personal Accident cover
(d)Each Dependant Parent : 20% of S.I. for the family under Hospialization & Personal Accident cover

9) Details of the persons to be covered (Self + Spouse + 2 Children below 21 years + 2 dependent parents)
(Age: 3months to 65 years only).

I II III IV V VI
NAME

Date of birth

Sex

Realtionship with the proposer
Do you suffer from hypertension
Do you suffer from Diabetes
Do you suffer from any cardiac ailment
Do you suffer from any disease /ailment
Existing disability, if any

8) Photographs of the Insured persons: - Please affix two photographs of each
insured person (Stamp size only)

I II III IV V VI

Name Name Name Name Name Name

9) Have you any existing Mediclaim Insurance : yes / no.
If yes 1) Name of Insurer :
2) Sum Insured :
(In case of existing mediclaim, settlement will be as per the rules of the Insurance Company).

10) Name of assignee (with regard to Section-II, Personal Accident):______________
______________________________________________________________________
11) Relationship of the assignee with the proposer: - _________________________
12) I do hereby authorise the Bank to debit my a/c._____________________ for applicable Premium _________________ / OR

Premium Rs.___________________ paid by Cheque No._____________ Date________

Cash Debited to A/c. No.______________________ Date_____________________

Declaration

I hereby declare and warrant that the above statements are true and complete. Myself and Family members are maintaining good health subject to item nos. 7(v) & 7(vi). I have read the salient features of the policy and willing to accept the coverage subject to the terms, conditions and exclusions prescribed by the Insurance Company as per the agreement between UCO Bank and National Insurance Company Limited. I understand that in case of any claim under the policy, UCO Bank will not undertake any responsibility or will not accept any correspondence and the same have to be pursued with the Insurance Company in case of PA Claim and TPA in case of Hospitalisation Claim. I have read the terms and conditions of the scheme and I shall abide by the same.
Place: ______________
Date: ______________ SIGNATURE OF THE PROPOSER.

FOR OFFICE USE ONLY

Premium paid by _____________ dated _____________ for Rs.____________.

Place: ______________

Date: ______________ SIGNATURE OF THE BRANCH MANAGER

PROHIBITION OF REBATES

(1) No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take 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 a part of commission payable or any rebates of the premium-shown on the policy nor shall any person taking out or renewing or continuing a policy except any rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
(2) Any Person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.