SP

C -

01-

10-1

4-1L

-PO

:122

Dec

lara

tio

n :

I her

eby

decl

are,

on

my

beha

lf an

d on

beh

alf o

f all

pers

ons

prop

osed

to b

e in

sure

d, th

at th

e ab

ove

stat

emen

ts, a

nsw

ers

and/

or p

artic

ular

s gi

ven

by m

e ar

e tr

ue a

nd c

ompl

ete

in a

ll re

spec

ts to

the

best

of m

y kn

owle

dge

and

that

I am

aut

horiz

ed to

pro

pose

on

beha

lf of

thes

e ot

her p

erso

ns. I

und

erst

and

that

the

info

rmat

ion

prov

ided

by

me

will

form

the

basi

s of

the

insu

ranc

e po

licy

is s

ubje

ct to

the

Boa

rd a

ppro

ved

unde

rwrit

ing

polic

y of

the

insu

ranc

e co

mpa

ny a

nd th

at th

e po

licy

will

com

e in

to fo

rce

only

afte

r ful

l rec

eipt

of t

he p

rem

ium

cha

rgea

ble.

I fu

rthe

r dec

lare

that

I w

ill n

otify

in w

ritin

g an

y ch

ange

occ

urrin

g in

the

occu

patio

n or

gen

eral

hea

lth o

f the

life

to b

e in

sure

d/pr

opos

er a

fter t

he p

ropo

sal h

as b

een

subm

itted

but

bef

ore

com

mun

icat

ion

of th

e ris

k ac

cept

ance

by

the

com

pany

. I d

ecla

re a

nd c

onse

nt to

the

com

pany

see

king

med

ical

info

rmat

ion

from

any

doc

tor o

r fro

m a

hos

pita

l who

at a

nytim

e ha

s at

tend

ed o

n th

e lif

e to

be

insu

red/

prop

oser

or f

rom

any

pas

t or p

rese

nt e

mpl

oyer

con

cern

ing

anyt

hing

whi

ch a

ffect

s th

e ph

ysic

al o

r men

tal h

ealth

of t

he li

fe to

be

assu

red/

prop

oser

and

see

king

info

rmat

ion

from

any

insu

ranc

e co

mpa

ny to

whi

ch a

n ap

plic

atio

n fo

r ins

uran

ce o

n th

e lif

e to

be

assu

red/

prop

oser

has

bee

n m

ade

for t

he p

urpo

se o

f und

erw

ritin

g th

e pr

opos

al a

nd/o

r cla

im s

ettle

men

t. I a

utho

rize

the

com

pany

to s

hare

in

form

atio

n pe

rtai

ning

to m

y pr

opos

al in

clud

ing

the

med

ical

reco

rds

for t

he s

ole

purp

ose

of p

ropo

sal u

nder

writ

ing

and

/or c

laim

s se

ttlem

ent a

nd w

ith a

ny G

over

nmen

tal a

nd/o

r Reg

ulat

ory

auth

ority

. The

term

inol

ogy

in th

e pr

opos

al fo

rm w

ith th

e te

rms

and

cond

ition

s of

the

polic

y an

d sc

hedu

le a

re e

xpla

ined

to m

e in

ver

nacu

lar l

angu

age

(mot

her t

ongu

e). I

als

o co

nfirm

that

the

sour

ce o

f fun

ds fo

r pre

miu

m p

aid

unde

r the

pol

icy

is le

gal.

In c

ase

of s

ingl

e A

dult

bein

g co

vere

d al

ong

with

chi

ldre

n/ch

ild: I

her

eby

conf

irm a

nd w

arra

nt th

at I

am s

ingl

e pa

rent

of t

he C

hild

/Chi

ldre

n pr

opos

ed

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Phone : 044 - 2828 8800 Fax : 044 - 2831 9100

9

CIN : U66010TN2005PLC056649 Email:info@starhealth.in Website: www.starhealth.in IRDA Regn. No: 129

Please check brochure for the available sum insured option in respected of each product

10.

11.

The company will not be on risk until the proposal has been accepted and

full payment of premium has been received.

Name of the Bank Name of the Branch of the Bank

Type of Account Account Number IFSC Code no.of the Branch

Please attach a photo copy of cancelled cheque leaf of the above Bank Account.

Policy Issuing Office

Date of Birth5 6 7 8

No

min

ee’s

ag

e an

d D

ate

of

Bir

th

Gen

der

2. H

ave

you

cons

ulte

d/ta

ken

trea

tmen

t/bee

n

adm

itted

for

any

illne

ss/d

isea

ses/

inju

ry/

S

urge

ry If

yes

, det

ails

.

h)A

ny g

ynae

colo

gica

l di

sord

er s

uch

as D

UB

, F

ibrio

d U

teru

s, O

varia

n cy

st

or h

ave

you

unde

rgon

e ce

sara

ean/

Hys

tere

ctio

ny If

yes

, S

ince

whe

n

43 A

ny

com

plic

atio

n d

uri

ng

/ fo

llow

ing

bir

th

if y

es, p

leas

e su

bm

it a

ll n

eces

sary

do

cum

ents