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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:[email protected] 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
