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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

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 Company’s 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.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & condition of the Niva Bupa health insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

I agree that the Company may provide my relevant details to the service providerto contact me to provide the services under the benefit. I further agree and consent that tracking details on the mobile application are required by the Company and the service provider to track, record and calculate my eligibility to receive the benefits. I declare and consent through my own free will and without any duress that the Company and its authorized service provider may access and record these details on a periodic basis and use these details for calculating and according the benefits under the Policy. We are currently supporting Android and IOS version only

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

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 Company’s 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.

I have read and understood the entire features, disclosures, risk factors, exclusions and  of the Niva Bupa health insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

I 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 am authorized to propose on behalf of these other persons.

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 further declare that I 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & conditions of the Niva Bupa health Insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

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 Company’s 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.

I have read and understood the entire features, disclosures, risk factors, exclusions and  of the Niva Bupa health insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

I 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 am authorized to propose on behalf of these other persons.

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 further declare that I 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & conditions of the Niva Bupa health Insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

I 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 am authorized to propose on behalf of these other persons.

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 insurer 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & conditions of the Niva Bupa health Insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

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 Company's 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.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & conditions of the Niva Bupa health Insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.

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/We undertake that the loadings applicable have been informed and understood by me.

Premium payment may be made by policyholder alone and not by any third person on behalf of the policyholder except where it is not speculative and the third person has an insurable interest in the life assured.

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 may render any policy issued void.

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 Company's 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.

I have read and understood the entire features, disclosures, risk factors, exclusions and terms & conditions of the Niva Bupa health Insurance policy and wish to continue purchasing the policy through online mode.

I hereby consent to and authorize Niva 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 Company from time to time.

I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my consent to share my KYC details including Aadhaar No./ PAN with the Insurance Repository.

I have read, understood and accepted all Terms and Conditions & hereby authorize Niva Bupa Health Insurance or any of its Agents and/or third party(ies)/affiliates to contact me via SMS/Email/Phone/WhatsApp/Facebook or any other modes on my registered phone number over-riding my ‘DND’ registration to make welcome calls/SMS, service calls/SMS or any other commercial communication.