Max Bupa Proposal Form

Heartbeat Health Insurance Policy Proposal Form
Please fill up this form in CAPITAL LETTERS for yourself and each proposed insured person.
1. Proposer Details
Title
Name
Permanent Address
City
District
State
Pin code
Current Address
City
District
State
Pin code
Address for Communication
Permanent
Phone No. STD Code
Current
Landline No.
Mobile No.
(atleast one of landline and mobile number should be provided)

E-mail ID
PAN No.
(Mandatory for premium above Rupees one lac)
Marital Status
Single
Married
Divorced
Widow(er)
Separated
Nationality
Highest Educational Qualification
Occupation
Salaried
Lesser than matriculation

Post Graduate
Self employed
Student
Matriculation
Professional Course
Housewife
Graduate
Others
If salaried, specify designation

If self employed, specify business/occupation
Annual Gross Income (in Rs.)
Bank Details:
Bank Name
Branch
IFSC Code
City
Account Number
Account Type
Savings
Current
Coverage Selection: Section I

1. Plan details
Policy Type
Individual
Family Floater
Family First
If Family Floater, number of persons to be covered
If Family First, number of person to be covered
1 Adult + 1 Child
1Adult + 4 Children
2 Adults + 2 Children
1Adult + 2 Children
2 Adults
2 Adults + 3 Children
Adults__________
1 Adult + 3 Children
2 Adults + 1 Child
2Adults + 4 Children
Children __________
Please tick/fill the relevant boxes.
2. Proposed policy term

1 year
2 year
3. Sum Assured (in Rupees)

3.1 Individual/Family
Floater:
Silver
Gold
2 Lacs
3 Lacs
5 Lacs
15 Lacs
3.2 Family First:
Platinum
7.5 Lacs
20 Lacs
10 Lacs
50 Lacs
15 Lacs
1Cr
20 Lacs
Silver
Individual Base Sum Insured

Floater Sum Insured
Rs.1Lac
Rs.3Lacs
Rs.2Lacs
Rs.4Lacs
Rs.3Lacs
Rs.5Lacs
Rs.4Lacs
Rs.10Lacs
Rs.5Lacs
Rs.15Lacs
Gold
Individual Base Sum Insured
Rs.1Lac
Rs.10Lacs
Rs.3Lacs
Rs.20Lacs
Rs.2Lacs
Rs.15Lacs
Rs.4Lacs
Rs.30Lacs
Rs.3Lacs
Rs.4Lacs
Rs.5Lacs
Rs.5Lacs
Rs.50Lacs
Rs.10Lacs
Rs.15Lacs
Rs.5Lacs
Rs.15Lacs
Rs.10Lacs
Rs.20Lacs
Rs.15Lacs
Rs.30Lacs
Floater Sum Insured
Platinum Individual Base Sum Insured

Floater Sum Insured
Rs.50Lacs
50 Lacs
Please tick the relevant boxes.
4. Details of Persons Proposed to be Insured

Address for eldest person proposed to be insured
Proposed Insured
Permanent Address
District
City
State
Pincode
Current Address ( ) same as permanent address
City
District
State
Address for Communication
Proposed Insured 1
Title
Gender
Permanent
Pincode
Current
Name
Male
Father-in-law
Height (cm)
Female
Relationship with Proposer
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Others(Please specify)______
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others

Proposed Insured 2
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Student
Matriculation
Graduate
House wife
Post Graduate
Professional Course
Others

2
Proposed Insured 3
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others

Proposed Insured 4
Title
Gender
Name
Male
Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others

Proposed Insured 5
Title
Gender
Name
Male
Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others

Proposed Insured 6
Title
Gender
Name
Male
Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others
ProposedInsured
Insured
Proposed
78
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Student
Matriculation
Graduate
House wife
Post Graduate
Professional Course
Others

3
Proposed Insured 8
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others

Proposed Insured 9
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others
Proposed Insured 10
Title
Gender
Name
Male
Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others
Proposed Insured 11
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Matriculation
Student
Graduate
Post Graduate
House wife
Professional Course
Others
Proposed Insured 12
Title
Gender
Name
Male

Father-in-law
Height (cm)
Female
Self
Mother-in-law
Spouse
Grandfather
Weight (kg)
Son
Daughter
Grandmother
Date of Birth
Daughter-in-law
Grandson
Father
Granddaughter
Mother
Son-in-law
Nationality
Occupation
Salaried

Self employed
Student
Matriculation
Graduate
House wife
Post Graduate
Professional Course
Others

Note: Premium is for individual age bands and 3 geographical zones.
If you need more space please use extra sheets.
5. Nomination
In the event of the death of the proposer any payment due under the policy shall become payable to the nominee proposed in the form and
the receipt of the proceeds by such nominee would be sufficient discharge to the Company. Nominee for all other persons proposed to be
insured shall be the proposer himself/herself. The following section is to be filled by the proposer:
Nominee Name
Address of Nominee
6. Medical History
In order for Us to service you fully, please answer the questions below accurately to the best of your knowledge. Please ensure that you are
fully informed about the standard waiting periods and permanent exclusions that apply to the Max Bupa Health Insurance Policies.
Questions
Proposed
Insured
Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed Proposed
Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8 Insured 9 Insured 10 Insured 11 Insured 12
Name
Name
Yes
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
Name
No Yes
No
1) Within the last 2

years, have you
consulted a doctor
or a healthcare
professional?
years, have you
been to a hospital
for an operation
and/or an
investigation (e.g.
scan, x-ray, biopsy
or blood tests)?
3) Do you take
tablets, medicines
or drugs on a
regular basis?
months have you
experienced any
health problems or
medical conditions
which you/proposed
insured person
have/has not seen a
doctor for?
Note: In addition to the above, We may have additional questions for you or may ask you to undergo medical tests to complete your full medical assessment
7. Additional Information
If you have answered yes in response to any of the questions in section 6, please give full details here. If you need more space please use
extra sheets. If you are unsure whether any details are relevant, please include them.
Name of
Proposed
Insured
The
relevant
question
number
from
section 6
(Medical
History)
Please specify as
accurately as possible
the symptoms or the
medical condition.
Where applicable,
please state the area
of the body affected
(e.g. right leg, left eye).
When did the

symptoms start
and/or when was
the treatment
completed?
What treatment
did you receive and
when (please include
dates of treatment
and any medication
prescribed)?
What was the outcome of

the treatment (e.g. ongoing,
complete recovery, recurrent
or likely to recur)?
The following are the permanent exclusions under the Policy. For further details on the exclusions, please refer to the terms and conditions of
the Policy.
Addictive conditions and disorders; Ageing and puberty; Artificial life maintenance; Circumcision; Conflict and disaster; Congenital conditions; Convalescence
and Rehabilitation; Cosmetic surgery; Dental/oral treatment; Drugs and dressings for OPD Treatment or take-home use; Experimental treatment; Eyesight;
Health hydros, nature cure, wellness clinics etc; Hereditary conditions (specified); HIV and AIDS; Items of personal comfort and convenience; Alternative
Treatment (except for Consultation and Diagnostic Tests for Platinum policy holders only); Obesity; Out-patient Treatment; Psychiatric and Psychosomatic
Conditions ; Reproductive medicine - Birth control & Assisted reproduction; Self-inflicted injuries; Sexual problems and gender issues; Sexually transmitted
diseases; Sleep disorders; Speech disorders; Treatment for developmental problems; Treatment received outside India (except for treatment undertaken
under Emergency Medical Evacuation and hospitalization (for platinum Policyholders only) or Specified Illness cover for treatment abroad (For Platinum
Policyholders only) of the Policy document); Unlawful Activity; Unrecognised physician or Hospital, Genetic disorders; any other such permanent exclusions
as may be specified in the Schedule.
For all Insured Persons who are above 60 years of age as on the date of commencement of the first Policy Period, the conditions listed below will be subject
to a waiting period of 24 months and will be covered in the third Policy Year as long as the Insured Person has been insured continuously under the Policy
without any break.
Stones in the urinary system (example kidney/bladder) Stones in billiary system (example gall stones) Cataract Benign prostatic hypertrophy
Mennerghia fibroinyoma, uterine prolapse including any condition requiring hysterectomy Piles (Haemorrhoids) Hernia (inguinal/umbilical and gastric)
Degenerative disorders of knee/hip Chronic renal failure or end stage renal failure Retinopathy Diabetes and related treatments
If any Insured Person is 65 years of age or over on the date of commencement of the Policy, then max Co-payment would be applicable in accordance with
the table provided below, if any Insured Person is 65 years of age or over on the date of commencement of the current Policy Year, then it is agreed that
We will pay the percentage provided in the table below of the amount We assess for payment or reimbursement in respect of any claim made by that
Insured Person and the balance will be borne by the Insured Person.
Co-payment contribution table
No. of Years of Continuous renewal at or later than the age of 65 years
0 yr
1yr
2 yr
3 yr
4 yr or more
Percentage of any assessed claim amount payable by Us

80%
85%
90%
95%
100%
There could be certain declined risks as per the underwriting norms of the Company.
Based on our assessment of your health some conditions may have waiting periods or exclusions applicable to any/all of the
Proposed Insured.
Optional Coverage Selection: Section II
1. Deductible or Co-Payment
a.
Cost Sharing option(Available only for Silver SI options of Individual and Family Floater Plans):
By choosing one of the cost sharing options below you can get the corresponding discount in your premium calculations for this policy,
i. 1 Lac annual aggregate deductible.
ii. 2 Lacs annual aggregate deductible.
iii. 3 Lacs annual aggregate deductible.
Deductible option
Premium Discount percentage
1 Lac annual aggregate deductible.
25%
2 Lacs annual aggregate deductible.
33%
3 Lacs annual aggregate deductible.
45%
b.
You can choose only one option marking Yes
Optional Co-payment for insured persons younger than 65 years: By choosing one of the two co-payment option below you can avail a
reduction in the premium of this policy. This option is only available for policies where none of the proposed insured persons are 65 years
or older.
Co-payment and discount option
Premium Discount
You can choose only one option marking Yes
10% co-payment for all claims that you submit to Us. 10%
20% co-payment for all claims that you submit to Us. 20%
2. Enhanced geographical coverage for
a. Emergency Medical Evacuation and Hospitalization benefit and
b. Specified Illness treatment abroad benefit.
Platinum customers with sum insured of 15 lacs, 20 lacs, 50 Lacs, 1 Cr or with Family First option can enhance their coverage for the above 2
benefits, to include pre-authorized treatment in US and Canada as well, by paying additional premium.
Would you like to include US and Canada in the covered geographic area for the above 2 benefits?
Yes
No
3.
Health Relationship Loyalty Program
You can choose anyone from the below mentioned options of Health Relationship Loyalty Program if you renew the policy continuously without any break.
Option 1: Loyalty Points worth 10% of last paid premium which can be redeemed against various products and services
Option 2: 10% additional Sum Insured of expiring base Sum Insured upto a max of 50% of current base Sum Insured
6
General Selection: Section III

1. Family Physicians Details
Family Physicians Name
Address
City
District
State
Pin code
2. Checklist of Documents
a. ID Proof
Passport
b. Age Proof
School/College Leaving Certificate
PAN Card
Driving License
Voter ID
Driving License
Passport
Letter from Recognised Public Authority

PAN Card
Letter from Recognised Public Authority
Others
Voter ID
Others
3.
3. Existing
Existing Insurance
Insurance Details
Details
Is the proposer or any of the persons proposed to be insured already insured under or proposed for a health insurance policy for
in-patient hospitalisation with Max Bupa Health Insurance Company Limited or any other insurance company.
If yes, please indicate below the Policy/Application number(s). (Please mention the application number in case of a pending proposal)
Since when have you been continuously insured
each proposed insured person if they have been continuously insured)
Name
Policy No. / Application No.
(please provide the insurance history of atleast last 3 years for
Insured from (date)
To (date)
Sum Insured
Claim details (if any)
In addition to the information given above, please also submit to Us (as an annexure to this proposal form) all the policy documents
relating to the existing policy in order to avail the portability benefit from your existing insurance policy.
4. Renewal Payment Sign-up
Payment of renewal premium of your health insurance policy can be made every year through continuing your existing ECS instructions
with Us. Under this option, your policy can be renewed promptly, but subject to you completing all additional requirements of
information and documentation as may be required by Max Bupa.
Would you like to opt for the ECS renewal option at this stage?
Yes
No
If you have chosen Yes above please fill up the ECS Mandate form attached along with this form.
5. Caution
You are obliged to make a full and frank disclosure of all facts material to the assumption of risk in relation to you and every person proposed to
be insured that would influence our decision to issue policy, or the terms on which it is issued and You must not misrepresent any information
to Us. The obligation continues until the Policy is issued, and does not end with the submission of this proposal form. If therefore, there is any
change in the information given herein or new information comes to light before the Policy is issued, then you must inform Us of the same in
writing without delay. If there is insufficient space to provide additional information, whether as requested or otherwise, then please attach an
extra sheet duly signed. If the disclosure obligations are breached then this may render any policy issued void.
6. Authorisation (Please read carefully and put a check mark against each before signing)
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting
policy of the insurance company and that the policy will come into force only after full receipt 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 life to be insured/proposer
after the proposal has been submitted but before communication of the risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on
the life to be insured/proposer 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 Government and/or Regulatory authority.
I consent to and authorize any of Companys authorized representatives not being direct employees of the Company to seek medical
information required for the purpose of policy issuance or claim settlement under this policy from any hospital/medical practitioner that I or any
person proposed to be insured/insured has attended or may attend in future concerning any disease or illness or injury.
Authorization for electronic policy fulfillment and service communications
I hereby consent that the policy documents may be sent to me by email at _______________________________(Please provide us your e-mail id)
I hereby consent to and authorize Max Bupa Health Insurance Company Limited( Company) to make welcome calls, service calls or any other
communication (electronic or otherwise) with respect to the proposed or existing policy of the Company from time to time.
Dated
Place
Signature of the Proposer

Name of Proposer
7. 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.
Dated:
Place
Signature of the Proposer

Name of Proposer
8. Vernacular Declaration
I hereby declare that I have fully explained the contents of the proposal form and all other documents incidental to availing the health insurance
from Max Bupa Health Insurance Company Limited to the Proposer in the language understood by him/her. The same have been fully
understood by him/her and the replies have been recorded as per the information provided by the Proposer. Replies have been read out to, fully
understood and confirmed by the Proposer.
Declarants Name:
Address:
City
Signature of declarant:
Pin Code
Signature of applicant in vernacular:
Acknowledgment
Proposal Form No.
Date
We acknowledge with thanks the receipt of your proposal and amount by Cash/Cheque/Demand Draft/ Others ________________________ of
amount of Rs. ___________________________ dated ___________________________ drawn on ____________________________ .
Neither the submission to Us of a completed proposal for insurance nor any payment for any policy sought obliges Us to agree to issue a policy,
which decision is and always shall be in our sole and absolute discretion. If We accept a proposal for insurance, it shall be subject to the policy
terms and conditions and We shall have no liability whatsoever if premium is not received by Us in full and in time or is not realized. If We do not
accept the proposal, We will inform you and refund the payment, if any, received from you without interest.
Signature of the receiver and office seal
8
For Office Use Only

Premium Payment Details:
Cash
Amount
Cheque/DD No.
Credit Card (16 digit no)
Date
Bank Name/Branch
Max Bupa Branch Location
Code No.
Business Sourced By: Advisor/DST/Corporate Agency/Other Channels
Code No.
Name
Code No.
Proposal Received On: Date

Processed By
Date
Approved By
Date
Customer ID
Additional Details for Bancassurance Channel only

Branch Code
SP Code
RM/LG Code
Customer Account No
Insurance Advisors Report

1. Name of the Proposer
2. Are you related to the Proposer?
Yes
No
3. If yes, nature of relationship?

4. Is this a proposal form for yourself?
5. Since when do you know the Proposer?
Yes
No
Years
6. Are you satisfied with the identity of the Proposer?
Months
Yes
No
7. Does the Proposer have any physical deformity/defect or mental retardation?
Yes
No
8. Have you explained the exclusions of the policy and has the Proposer personally completed the health declaration?
Yes
No
9. What is the Proposers state of health at the time of making of this proposal form?
10. Do you recommend acceptance of this proposal form considering all the factors, including moral hazard?
Date :
Yes
No
Signature of the Insurance Advisor
STATUTORY WARNING AS PER SECTION 41 OF THE INSURANCE ACT 1938

PROHIBITION OF REBATES
Payment of rebates is expressly prohibited under Section 41 of the Insurance Act, 1938.
1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in
respect of any kind or risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy nor shall any person taking out or continuing a policy accept any rebate except such rebate as may be allowed in
accordance with the prospectus or tables of the Insurer.
2. Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend to five hundred rupees.
Max Bupa Health Insurance Company Limited

Corporate Office: Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Registered Office: Max House, 1, Dr. Jha Marg, Okhla, New Delhi - 110020
www.maxbupa.com
Max and Max Logo are registered trademarks of Max India Limited. Bupa and the HEARTBEAT logo are the registered service marks of The British United Provident
Association Limited. All these marks are being used under license by Max Bupa Health Insurance Company Limited. Insurance is the subject matter of solicitation
Neither the submission to us of a completed proposal for insurance nor any payment for any policy sought obliges us to agree to issue a policy,
which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, it shall be subject to the policy
terms and conditions and we shall have no liability whatsoever if premium is not received by us in full and in time, or is not realised.
If we do not accept the proposal, we will inform you and refund payment, if any, received from you, without interest.
This page is not a part of the proposal form. In case you want to take the option of
paying renewal premium through ECS, then you are requested to fill up this ECS form.
Key Feature Document

Heartbeat
Max Bupa is dedicated towards being fair and transparent with its customers. This document summarizes key features and major exclusions in your
policy. Please read it carefully to understand your policy better.
Room Rent/Hospital Accommodation: Indicates the level of room rent a patient is eligible for.
Heartbeat Individual
and Floater
Silver Plan
Gold Plan
Platinum Plan
Shared Room or 1% of
the Sum Insured
Single Private Room
No Limit
It is important to note that the total claim amount is deducted if room rent opted is more than the eligibility. For e.g. If the room rent limit in policy
for an insured is Rs.3000/day, you can opts for Rs.6000/day room and the total hospitalisation bill is Rs.50,000/- then we shall pay reasonable and
customary charges i.e. equivalent of cost of same treatment incurred in Rs.3000/- room rent in the same/equivalent hospital on our network.
Pre Existing Disease (P.E.D): Any condition/illness/injury which the insured person has suffered from before issuance of policy is classified as
P.E.D. Claims with respect to P.E.D are not payable till the completion of waiting period i.e. 48 months (in case of silver plan) / 24 months (in case of
gold/platinum plan) since inception of the policy and continuous renewal.
International Medical treatment and Assistance: Emergency medical evacuation and Specified Illness treatment abroad are covered in
platinum plans only. This benefit is applicable worldwide excluding USA and Canada. USA and Canada may be included by paying additional
applicable premium.
Maternity: Medical expenses for Maternity and all pregnancy related complications are payable post a waiting period of 24 months after
inception of the policy and subject to continuous renewals as per plan eligibility. Both Husband and Wife should be covered under the same policy
to avail maternity benefit.
Pre and Post hospitalisation expenses: Expenses incurred 30 days prior to hospitalisation and 60 days post hospitalisation are payable only
if hospitalisation is accepted for claim payment under the policy. If we have accepted the In-patient claim with a co-payment, then co-payment shall
be applicable for pre and post hospitalisation treatment as well.
Out Patient Benefits: OPD benefits are available in platinum plan only as per plan eligibility.
Optional Co-Payment: Customers less than 65 yrs age have an option to choose either a 10% or 20% co-payment to avail discount on premium.
No co-payment shall be applicable below the age of 65 unless this option is specifically chosen.
Compulsory Reducing Co-Payment above the age of 65 Yrs: Reducing co-payment starts at 20% and reduces by 5% for each continuous
year of cover. For e.g. if a customer has a continues coverage of 3 years prior to his/her commencement of 65th yrs of age, then the co-payment
applicable at the age of 65 yrs shall be 5% and 66th year of age onwards co-payment shall be nil.
Specific waiting period: For all Insured Persons who are above 60 years of age as on the date of commencement of the first Policy Period, 11
listed illnesses (such as Piles, Hernia, Degenerative disorders of knee/hip and Retinopathy) are subject to a waiting period of 24 months.
Portability Benefits: Waiver of waiting period(s) is provided to the extent of period and Sum Insured already covered continuously and without
a break with any previous Indian retail health insurance policy as Insured.
Rise in Premium with age: your health insurance premium will increase gradually every year as insured person(s) age increases.
Health Relationship Loyalty Program: The customer has an option to choose at commencement or renewal of the policy, between loyalty
points or enhancement of sum insured (S.I). The loyalty benefit shall be passed on if the Policy is renewed without any break. Switching from S.I
enhancement to Loyalty point option cannot be done.
Health Check-up: Max Bupa will cover the cost of a health checkup every year in case of Gold/Platinum plan and once in two years in case of
silver plan.
Member addition/deletion: Any addition or deletion of the member(s) in the policy can be done only at the time of renewal.
Free Look Provision: If you do not agree to the terms and conditions of the policy, you may cancel the policy stating reasons within 15 days of
receipt of the policy document provided no claim(s) have been made. Premium shall be refunded post deducting charges for medical checkup,
stamp duty and proportionate risk premium for the period on cover. The free look provision is not applicable at the time of Renewal of the Policy.
NOTE: THESE ARE ONLY SUMMARY OF THE COVERS OFFERED. PLEASE REFER TO THE POLICY WORDINGS FOR COMPLETE DETAILS BEFORE
CONCLUDING OF THE SALE; THIS DOCUMENT IS ONLY AN INDICATOR FOR KEY BENEFITS IN THE POLICY.
Date: __________________
Signature of Proposer: _______________
Place: __________________
Name of Proposer: _________________
Insurance is the subject matter of solicitation . Max Bupa Health Insurance Company Limited. IRDA Registration
number 145. 'Max', 'Max logo', 'Bupa' and HEARTBEAT logo are trademarks of their respective owners and are being
used by Max Bupa Health Insurance Company Limited under license.

Max Bupa Proposal Form

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Max Bupa Proposal Form

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Heartbeat Health Insurance Policy Proposal Form

Address for Communication

Phone No. STD Code

(atleast one of landline and mobile number should be provided)

(Mandatory for premium above Rupees one lac)

Lesser than matriculation

If salaried, specify designation

Coverage Selection: Section I

If Family Floater, number of persons to be covered

If Family First, number of person to be covered

Please tick/fill the relevant boxes.

2. Proposed policy term

3. Sum Assured (in Rupees)

3.2 Family First:

Individual Base Sum Insured

Individual Base Sum Insured

Floater Sum Insured

Platinum Individual Base Sum Insured

Please tick the relevant boxes.

4. Details of Persons Proposed to be Insured

Current Address ( ) same as permanent address

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

If self employed, specify business/occupation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

If self employed, specify business/occupation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

If self employed, specify business/occupation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

If self employed, specify business/occupation

Relationship with Proposer

Lesser than matriculation

If salaried, specify designation

If self employed, specify business/occupation

Relationship with Proposer

1) Within the last 2