Heritage I 6/06/03

@ The New India AssuranceCom rany Limited

87, M. G. Road,Fort, Mumbai, India - 001.

PROPOSALFORM FOROVERSEASMEDI POLICY

(Business& Holiday)

(To be submitted in Original with 2 r es)

(Available to personsin the age group of 6 mo i to 70 years)

IMPORTANT
PLEASE MAKE SURE YOU READ AND FULLY UNDERSTAND TH ] DOCUMENT BEFORE YOU
TRAVEL FROM THE REPUBLIC OF INDIA.

FAILURE TO FOLLOW THE INSTRUCTION GIVEN COULD RESULT I REJECTION OF ANY CLI\IM
THAT MIGHT BE MADE.

THE OVERSEAS MEDICLAIM POLICY PROVIDES INDEMNITY F( IR EXPENSES NECESSARILY

INCURRED FOR IMMEDIATE TREATMENT OF ILLNESS, DISEASESCC NTRACTED OR INJURY FI]R.ST
SUSTAINED (DURING THE PERIOD OF INSURANCE OF OVERSEAS ]RAVEL SUBTECTTO POLICY
TERMSAND CONDITIONS).

POLICY ALSO OFFERSPERSONAL ACCIDENT COVER

UNDERSELECTEDPLANS, FOLLOWING ADD ON COVERSAREOFFE] E D :

- TOTAL LOSSOF CHECKED IN BAGGAGE
- DELAY OF CHECKED IN BAGGAGE
- LOSSOF PASSPORT
- PERSONALLIABILITY

AND IN ADDITION ALSO PERSONAL ACCIDENT, TOTAL LOSSOF CH ]CKED BAGGAGE,DELAY OF

CHECKED BAGGAGE, LOSS OF PASSPORTAND PERSONAL LIABII ,ITY COVERS. (DURING THE
PERIODOF INSURANCE OF OVERSEASTRAVEL SUBIECTTO POLICY: ERMSAND CONDITIONST'|

IN THE ABSENCE OF MEDICAL REPORTSAS SPECIFIEDiN ITEM II I SUM INSURED WILL STAND
REDUCED TO AN EQUIVALENT AMOUNT OF US$ 10,000 rN RESP iCT OF MEDiCAL EXPENIJES
INCURRED THROUGH ILLNESS OR DISEASE ONLY, SUBJECTTO E (CLUSION OF PRE-EXISTING
DISEASE.

THE ATTENTION OF THE PROPOSER IS DRAWN TO ITEM II (]\ IEDICAL HISTORY) OF THE
PROPOSALFORM ESPECIALLY IN RELATION TO PREVIOUSTREATMj ;NT FOR ILLNESSORDISEI\.SE
SUCH AS RENAL DISORDERS, OR DISEASES, CEREBRAL OR V \SCULAR STROKES, HE,ART
AILMENT OF ANY KIND, MALIGNANCY, TUBERCULOSIS, ENC IPHALITIS, NEUROLOGICAL
DISORDERS, GALL BLADDER DISORDER, ARTHRITIS REQUIRIN ] SURGERY AND IF ANY
TREATMENT HAS BEEN RECEIVEDFOR ANY OF THE ABOVE DISO] DERS AT ANY TIME IN THE
PAST,SUCH TREATMENT MUST BE DISCLOSEDTO THE POLICY ISSUI .lG OFFICE.
NEITHER THE INSURERSNOR CLAIMS SETTLING AGENTS SHALL BE RESPONSIBLEFOR
THE AVAILABILITY, QUALITY OR RESULTSOF ANY MEDICAL TREA OR THE FAILURE O,F
THE INSURED TO OBTAIN MEDICAL TREATMENT.

THE PROPOSALFORM SHOULD BE COMPLETED TO THE BESTOF Y R KNOWLEDGE AND BEI-,IEF,

AND ALL MATERIALFACTSSHOULDBEDISCLOSED.
FAILURETO SO MAY NULLIFY COVEN|.
UNDERTHEPOLICYFSUED.

NOTE: PlanA- 1& A- 2 (Worldwide travel excludingUSA /

Plan B - 1 & B - 2 (Worldwide travel including USA / )

Plan E - 1 & E - 2 ( CorporateFrequentTravel to all ns including USA / Canada)

Plan K (For travel to Asian countries - Japan not inclu

Medical Reportsare required

A) Trip is for period over 60 days and if

insured personif over 60 yrs of agevisitin USA/Canada

insured is over 70 yrs of age and v iting countries other than
USA/Canada.

B) Proposalrevealsthat insured had sufferedfrom suffering from any illness /

disease.

the Proposal Form should be accompaniedwith 1) ECG ntout with report and 2)
Fasting blood Sugar and Urine Sugar Urine Strip Test Re rt or any other medical
report required by the company etc. along with the a questionnaire II(B) to be
completedand signed by the Doctor with minimum M. D. ification conducting the
test. In the absenceof such nnedicaltests and reports due a shortageof time before
travel, cover may still be granted subjectto a satisfactory roposal form but the sum
insured under policy, in respect of expensesincurred for he treatment of illness or
diseaseshall be restricted to US $ 10,000only, which shall cover the cost of Medical
treatment for pre-existing disease. In case of accident ho er the full sum insuled
benefit would be available.
 -2-

I. GENERAL INFORMATION.

1. NAME OF THE PROPOSER MR./M /Mrss./MASTER

(IN BLOCK LETTERS) AS STATED
IN THE PASSPORT.

2. HOME ADDRESS& TELEPHONENO.

3. PROPOSER'SACTUAL OCCUPATION
(Specify)

4. OFFICEADDRESS

5. TELEPHONE NO.

6. AGE (IN COMPLETEDYEARS) ATE OF BIRTH

7. PASSPORTNO.
DATEOFEXPIRY&
ISSUINGAUTHORITY
NAME OFPASSPORT

8. PLAN OPTED FOR TA - 1 nA - 2 rEE[]

B- 1 B -2 E-1 E-2
(Pleasetick relevant plan) K:_

9. PURPOSEOF VISIT
(BUSINESS/ HOLIDAY TRAVEL)

10. PROPOSEDDATE OF DEPARTURE FROM DAY MONTH YEAR

OF INDIA i.e.FIRSTDAY OF
REPUBLIC
INSURANCE

11. INSURANCEREQUIREDFOR
(Numbersof days)

N.B. : 1. In case of anv extension of stav abroad, requi ing extension of policy,
period, approval of issuing office has to be o tained and appropriat<:
premium paid before expiry of policy. Request such extensionshoulcl
be supported with a declarationof good health.

2. In caseof early return partial refund of premiu will be permitted if tht:

original cover is for minimum period of 60 days nd unexpired period ir;
not lessthan 14 days and also if no claim is lod under the policy.

12. COUNTRIESTO BEVISITED

(State approximate number of days at
each place)
 -3-

13. NAME, REGISTRATION NO.,

ADDRESS& TELEPHONENO.
OF FAMILY PHYSICIAN

il. MEDICAL HISTORY.

(A) TO BE COMPELTED BY THE PROPOSER

,NO' (A DASH
PLEASE ANSWER THE FOLLOWING QUESTIONS WITH OR Ei
NOT SUFFICIENT)AND GTVEFULL DETAILS :-

1. Are you in good health and free from

Physical and mental diseaseor infirmity.

2. Have you ever sufferedfrom any iliness

or diseaseupto the date of making this
proposal.

^
J. Do you have any physical defector deformity.

4. Have you ever beenadmitted to any hospital/

nursing home / clinic for treatment or
observation.

5. Have you sufferedfrom any illness/ disease

or had an accidentin the L2 months preceding
the first day of insurance.

6. If the answer is'yes' to any of the foregoing

ve full details as under :
Nature of illness / Date on which first First treatment Name of attending meclical
disease/ injury & treatment taken completed/ is practitioner / Surgeon,with
treatment received his address& Tel. Nos.
 -4-

7. a) Have you any intention of engaging in professional rts ?

b) If so, give details.

8. Pleasegive details of any knowledge of any positive xistenceof any ailment,

sickness or injury which may require medical attenti whilst on tour abroad.

I HEREBYDECLARE THAT

1,, I will not be travelling againstthe advice of a physicia

2. I am not on the waiting list of any medical treatment.
3. I will not be travelling for the purpose of obtaining m ical treatment.
4 I have not received a terminal prognosis for a medi al condition before this
duy.

Assignment:

L dohe asslgn the monies

payable under the policy in the event my death to
my .. . . . . .( lation to the insured)
Mr. / Mrs. / Miss./ Master. I further
declarethat his / her receipt shall be sufficient dischargeto t company.

I further declare that and warrant that the above statements are true and complete. I
consent to the insurers seeking medical information from doctor who has at any
time attended concerning anything which affectsmy physic 1 or mental health. and I
authorize the giving of such information to Coris Inter tional and / or their
programme medical advisers.I agree that this proposal s 1 form the basis of the
contractshould the insurancebe affected.

I am willing to accept the policy, subject to the terms, and conditions

prescribedtherein.

Signatureof Proposer. .. /
Day Month Year

Place:
 -5-

B) TO BECOMPTETED
BYTHE DOCTORI To be comp d by M. D. onlyl

1. a) History

b) Any past history of disease,operation,

accidents,investigation etc.

c) General Examination.

d) SystemicExamination.

2. Electrocardiography:

a) Does the attached Electrocardiogram in your

professional opinion show any abnormalities
if so, please describe :

b) Doesthe abnormality representa current il

or diseasewhich may possiblyrequire medical
treatment during proposer'sforthcoming trip ?

c) Doesthe Proposernow or did he/she in the

require medication for this abnormality ?

d) Pleasedescribeany treatment taken by rin

the past or being taken at present:
e) Do you recofiunendStressTest ? If so please tain the
report on such test.

3. Doesthe Blood/Urine Strip Test show any sugar?

4. Do you consider that Proposeris fit to travel anyw abroad, due accounl.
being taken of the stress of air travel adversely af ting his health/medical
condition ?

Signature of the Doctor

Name of the Doctor
Qualification
Address
TelephoneNo.