United India Insurance Company Limited
Corporate Office: 24, Whites Road, Chennai – 600 014
Regional Office : United India Towers 3-5-817 & 818 Floor No -2 Old Mla Qrtrs Road, Basheerbagh Hyderabad, Telangana - 500029
IRDA Registration No. 545. Visit: www.uiic.co.in
AB Arogyadaan Group Health Insurance Policy
FOR ACCOUNTHOLDERS OF ANDHRA BANK
PROPOSAL FORM
INSTRUCTIONS:
1. The form should be filled by the Proposer in block letters.
2. Fresh form to be submitted for cancellations/alterations.
3. (*) denotes mandatory fields.
PROPOSER DETAILS*:
Account No.* :
Proposer Name* :
(Main A/c holder only)
Communication :
Address*
(as per Bank records)
City*:
State*: Pin Code*:
Mobile*: Landline Number :
Contact Details :
Email ID* :
Nationality*: Indian NRI
PLAN DETAILS*: (Choose one plan)
PLAN A : (Account holder, Spouse, Two Dependent Children ) (1+3)
PLAN B : (Account holder, Spouse, Two Dependent Children, Parents)(1+5)
BASE COVER*:
SUM INSURED (in Rupees) (Choose any one):
2 lacs 3 lacs 4 lacs 5 lacs 8 lacs 10 lacs 12 lacs
OPTIONAL COVER : SUPER TOP-UP (available only if base cover of Rs. 10 lacs and above is chosen)
SUM INSURED (in Rupees) (Choose any one) :
5 lacs 10 lacs
MEMBER DETAILS*:
Please provide details of Insured Persons. Premium will be calculated on the basis of age of eldest member in the policy.
Name of Insured Members Relationship to Date of Birth Gender
account holder (DD/MM/YYYY) Age (M/F)
(First*, Middle, Last*)
SELF
Insured 1
Insured 2
Insured 3
Insured 4
Insured 5
Insured 6
NOMINEE DETAILS: (FOR PROPOSER); FOR ALL OTHER MEMBERS, PROPOSER WILL BE THE DEFAULT NOMINEE
Nominee Name*:
Relationship With Insured*:
URN NO. : ……………………………………..
MEDICAL INFORMATION*:
Have you or any of the proposed insured member s:
Ever suffered from, taken treatment, been hospitalized or been recommended to undergo investigations / YES NO
surgery / take medication in the past 36 months for any ailment other than for childbirth, malaria, dengue, flu,
or for completely healed minor injuries/diseases?
Suffered or currently suffering from any pre-existing illness / disease / injury / disability / physical or mental YES NO
defects / or any condition that may affect mobility / sight / hearing / speech?
Note: If answer is YES to any of the above questions, the member is not eligible to be enrolled under this policy.
DEBIT AUTHORIZATION*
I hereby authorize Andhra Bank (Branch Name) to debit my account number
with the bank for ` xxxxxX towards payment of first premium for availing this health insurance policy
ECS/SI Consent
I hereby authorize United India Insurance Company Limited to charge premium for the policy through ECS debited from my account for any Premium
amount as and when due till further written notification and so long as my bank account being operational. I understand that the cover will start on
remittance being received by United India Insurance Company Limited from the Bank. I hereby request and authorize the Bank to debit the my account
number on the yearly due dates with the applicable renewal premium. I understand that the premium is subject to change due to change in service
tax and other levies as specified by the Govt. of India.
Declaration & Authorization
• I/We 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/We am/are authorized to propose on behalf of these other
persons.
• I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at any time has attended
insured/proposer concerning anything which affects the physical or mental health of the proposer and seeking information from any insurance
company to which an application for insurance has been made for the purpose of underwriting the proposal and/or claim settlement.
• I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal
underwriting and/or claims settlement and with any Government and/or Regulatory authority.
Date*: D D M M Y Y Y Y
Proposer’s Signature*:
Place*:
DISCLAIMER:
United India Insurance Company Ltd. shall not be responsible / liable to anybody, in any manner, whatsoever for non-debit / delayed debit of any payment
due in relation to insurance policy into above bank account of Proposer/Policy holder and any other consequential loss directly / indirectly. Neither the
submission of a completed proposal for insurance or any payment for any Policy sought oblige the Company to agree to issue a Policy, which decision
is and always shall be in the Company's sole and absolute discretion. If a proposal is not accepted, United India Insurance Company Limited will inform
you and refund any payment received from you without interest.
Insurance is a subject matter of solicitation.
Section 41 of the Insurance Act, 1938, Prohibition of Rebates:
(1) 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 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 prospectuses or tables of
the insurer: Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken
out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section
if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide
insurance agent employed by the insurer.
(2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to
ten lakh rupees.
(TO BE FILLED BY ANDHRA BANK)
Premium remitted BA Number: Date of debit: D D M M Y Y Y Y
for ` Branch Code:
Signature of the Bank Manager:
Original Form: To be submitted to RO Hyderabad, UNITED INDIA TOWERS 3-5-817 & 818 FloorNo -2 OLD MLA QRTRS ROAD
BASHEERBAGH HYDERABAD TELANGANA - 500029.
2nd Copy: For Andhra Bank branch; 3rd Copy: For Customer
