A2Z Assurance Private Limited

Please Fill Complete Proposal Form (Health Insurance Proposal Form)

Insurance Company *

Plan Type

Plan Name *

Covering Member *

Eldest Member Age Band *

Sum Insured *

Gross Premium *

Add-On Premium (if any)

Final Payable Premium *

Net Premium

Add-On Remarks

Please Note: All Plans are Standard Plans; for Complete Plan Details Please visit Insurance Company Website.

Payment Details

Account Name	Bank Name	Branch Name	Current Account No.	IFSC Code	MICR Code
A2Z ASSURANCE PRIVATE LIMITED	ICICI Bank Ltd.	Hisar Red Square Market	661605601215	ICIC0006616	125229103

Agent Referral Name

Payment Mode *

Payment Date *

Amount *

Chq/TXN No./Remarks

Payment Slip/Cheque/DD

Proposal Form

Aadhaar Card

PAN Card

Declaration/Consent Letter

Proposer Details

Proposer Name *

Proposer Gender *

Marital Status *

Occupation *

Family Monthly Income *

Date of Birth *

Insured Mobile No.

Insured Email ID *

Full Address *

Enter PIN Code *

City/District *

State *

Nominee Name *

Nominee DOB *

Nominee Relation *

Risk Start Date *

Policy Tenure

Policy Remarks

Details of Persons to be Insured

Insured Name *

Date of Birth *

Insured Gender *

Relation with Insured *

Height in CM *

Weight in KG *

Declaration : * 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 understand that the information provided by me will form the basis of the Individual Policy/floater Policy, and the proposal is subject to the Board approved underwriting policy of the Company and that the Policy will come into force only after Company’s full receipt and realization of the premium chargeable.
I/ We further declare that I/ we will notify in writing any change occurring in the occupation or general health of the Insured Person(s) to be insured/ proposer after the proposal has been submitted but before communication of the risk acceptance by the Company. Upon renewal of Policy, I/We agree to abide by the standard Terms and Conditions, unless otherwise mentioned by the Company in renewal Policy Schedule or attachments thereto.
I/ We declare and consent to the company seeking medical information from any doctor or from a hospital/institution who at anytime has attended on the Proposer/Insured Person to be insured or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/ proposer and seeking information from any insurance company to which an application for insurance on the life to be assured/proposer 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 reinsurer, Governmental and/or Regulatory authority.

Please Fill Complete Proposal Form (Health Insurance Proposal Form)

Payment Details

Proposer Details

Details of Persons to be Insured

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