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Group Mediclaim


Fields marked with * need to be completed
 

Proposer’s Details
Name of the proposer * 
Address for Communication * 
Business of the Proposer * 
Number of Employees to be Insured * 
Do you require Maternity Benefits extension?
 
What are the other extensions / benefits you want
 
Coverage of Pre-existing diseases
Waiver of first year exclusions
Waiver of 30 day waiting period
Family Floater
Removal of Domiciliary Hospitalisation Benefit
New Born cover
 
Period of insurance * 
From
To
Details of persons proposed for insurance (Please attach a separate list in the following format)
 
S.No Name of the employee Emp ID No Date of Birth Relationship with the Employee Gender Sum Insured
1
2
 
Details of previous / expiring insurance policy ?
No of Persons
Sum Insured
Incurred Claims Ratio
 
 

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