Landmark : _____________________________________ City :
State : Pin Code :
Date of Birth : / / (DD/MM/YYYY)
Landline : - Mobile :
E-mail :
Name :
Date of Birth : / / Relationship : (DD/MM/YYYY)
Nominee Details
Customer ID : Policy Tenure* : 5 years 4 years 3 years 2 years 1 year
Loan Account No : Loan Tenure : years
Loan Amount : LG/MO Code : Please mention your PF number
Union Rinn Suraksha - Plan 1 : Union Rinn Suraksha - Plan 2 :
(A) I do hereby authorize Union Bank of India to pay premium amount mentioned above on my behalf, to Religare Health Insurance Company Limited (Account No: 307801010918234), as premium towards issuance of a certificate of insurance against this application for GCPP – Union Rinn Suraksha Scheme.
(B) I declare that I have never been diagnosed with or been under treatment for any disability, deformity, terminal illness or any illness/ disease restricting activities (e.g. Epilepsy/Seizure disorder). My nature of duties/Occupation does not require me to be involved in any hazardous activity, operating heavy machinery, handling hazardous material (chemicals/poisons/toxins/ explosives/radioactive materials), working at heights or underground, oil rigging, high voltage, high temperature, working in aircrafts or sea going vessels, operating arms and ammunitions, employment with armed forces or engaging in adventurous sports.
I declare that all the information which is relevant to this Application Form has been disclosed and not withheld. I further declare and agree that this declaration and the answers given above shall be held to be promissory and shall be the basis of the contract between me and the Insurer.
Name of Applicant : _______________________________________________ Signature :_______________________ Date_______________
Page 1
Application Form
For Branch Use Only
Transaction ID : _________________________________________ Application No :__________________
Accidental DeathPTDPPDChild EducationAccidental HospitalizationEMI Cover – for all hospitalization
Premium Chart(Premium amounts are in` & Inclusive tax)
Plan 1
` 5 Lakhs` 10 Lakhs (as per PTD* Table)` 10 Lakhs (as per PPD* Table)Up to 10% of SI` 1,00,000• >3 Days and <=8 Days: Fixed Benefit= ̀ 10000 • >8 Days and <=13 Days: Fixed Benefit= ̀ 20000• >13 days: Fixed Benefit= ̀ 30000 • For policy tenure: 5 years; Premium: ̀ 6,296.0• For policy tenure: 4 years; Premium: ̀ 5,176.0• For policy tenure: 3 years; Premium: ̀ 3,987.0• For policy tenure: 2 years; Premium: ̀ 2,728.0• For policy tenure: 1 year ; Premium: ̀ 1,399.0
Exclusions
Non-eligible Professions
• People working in Mines & Oil and Gas Industry.• Crew Employed In Ships (Merchant Navy when in Duty).• Laborers working in the Construction Industry.• Professional Sports Persons.• Airline Cabin Crew including Pilots.• People Associated with Racing & Adventure Sports Including and not limited to River Rafting, Paragliding, Skydiving etc.• Armed forces (Army, Navy, Air force including armed guards).• Chemical Industry Workers.• Glass workers including Workers working in Glass Furnaces.
• Furnace Operators.• People working underground or at heights.• People working with Explosives and Firecrackers.• Entertainment Industry workers.• Social services, Religious organizations or charitable (non-profit) organizations.• Fire, police or Private Security Guards.
Permanent Exclusions
Any Claim in respect of any Insured Member, arising out of or directly or indirectly due to any of the following shall not be admissible, unless expressly stated to the contrary elsewhere in the Policy:
(a) Any Medical Expenses unless covered by way of an applicable Benefit;
(b) Any illness including any pre-existing condition or its complications except where an Insured Event under Clause 2 or Benefit 1 results from an illness which arises directly as a consequence of an Injury which is sustained during the Cover Period;
(c) Any pre-existing injury or physical condition;
(d) An Insured Member operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft or Scheduled Airline or any airline personal;
(e) An Insured Member flying in an aircraft other than as a fare paying passenger in a Scheduled Airline;
(f) Any intentional self- inflicted Injury, suicide or attempted suicide, sexually transmitted conditions, mental or nervous disorders, insanity;
(g) Influence of drugs, alcohol beyond the medically permissible limit or other intoxications or hallucinogens;
(h) War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds;
(I) Participation in actual or attempted felony, riot, civil commotion or criminal misdemeanor;
(j) A complication of infection with Human Immune Deficiency Virus (HIV) or any variance including Acquired Immune Deficiency Syndrome (AIDS) and AIDS Related Complex (ARC) or venereal disease;
(k) Training for or participating in professional sport of any kind;
(l) Any act resulting in breach of law committed by Insured Member with criminal intent;
(m) The Insured Member serving in any branch of the military, navy, air force or any branch of armed forces or any paramilitary forces;
(n) Radioactive contamination whether arising directly or indirectly ionizing radiation, toxic, explosive or other hazardous properties of nuclear material;
#*PTD & PPD table will be available on request from any Union Bank of India Branches. Union Rinn Suraksha Plan 2 is available for the customers having loan 5 Lacs and above.
#Plan 2
` 10 Lakhs` 20 Lakhs (as per PTD Table); Depending on Severity` 20 Lakhs (as per PPD Table); Depending of SeverityUp to 10% of SI` 2,00,000• >3 Days and <=8 Days: Fixed Benefit= ̀ 10000• >8 Days and <=13 Days: Fixed Benefit= ̀ 20000• >13 days: Fixed Benefit= ̀ 30000• For Policy tenure 5 years; Premium: ̀ 9,900.0• For Policy tenure 4 years; Premium: ̀ 8,139.0• For Policy tenure 3 years; Premium: ̀ 6,270.0• For Policy tenure 2 years; Premium: ̀ 4,290.0• For Policy tenure 1 year ; Premium: ̀ 2,200.0
Page 3
Declaration
I ___________________________________, do hereby authorize Religare Health Insurance Company Limited to credit any proceeds against claim (in case of
Accidental Death and Permanent Total Disability) or premium refunds in my loan account no. ___________________ or any other loan financed by Union Bank
of India under the coverage provided through this application.
Name of Applicant _____________________________________Signature___________________________________________Date_______________
(o) Insured Member working in or with Underground mines, tunneling or explosives or involving electrical installation with high tension supply or conveyance testing or oil rigs or ship crew services or as jockeys or circus personnel or aerial photography or engaged in any Hazardous Activities as.
(p) Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
(i) Nuclear attack or weapons mean the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile or fusion material emitting a level of radioactivity capable of causing incapacitating disablement or death.
(ii) Chemical attack or weapons mean the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death.
(iii) Biological attack or weapons mean the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death.
In addition to the foregoing, any loss, claim or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, minimizing or in any way relating to the above is also excluded;
(q) Resulting from pregnancy or childbirth;
(r) Impairment of the Insured Member’s intellectual faculties by abuse of stimulants or depressants or by the illegal use of any solid, liquid or gaseous substance.
(s) Resulting due to any disease or infection except where such condition arises directly as a consequence of an accident during the Cover period.
Name of Applicant _____________________________________Signature___________________________________Date_______________________
