Professional Documents
Culture Documents
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in
Version 2
Format for Business Acceptance / Quote - GMC
I Insured / Proposer Details
1 Name of the Insured / Proposer
2 Address of the Insured / Proposer
3 Location of the persons to be covered
4 Business of the Insured / Proposer
5 Name of the contact person of the Insured / Proposer
6 Contact number of the Insured / Proposer
7 E-mail id of the Insured / Proposer
8 Website Address of the Insured / Proposer
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Star Health and Allied Insurance Company Limited
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in
Version 2
Format for Business Acceptance / Quote - GMC
4.1 Policy Type FLOATER
4.2 Waiver of waiting period of 30 days YES
4.3 Waiver of first year exclusions Y
4.4 Waiver of First two year exclusions Y
4.5 Cover for PED Y
4.6 Cover for Maternity NO
Limit of coverage for Maternity For Normal : For Ceasarian :
4.12 Any other coverages offered under expiring policy Please mention.
Policy copy with terms / conditions including extensions is to be mandatorily provided by the proposer
Premium under expiring policy as at the inception
5 Rs.
(excluding service tax)
Refund premium on account of deletions during the year
6 Rs.
(excluding Service Tax)
Additional premium on account of additons during the year
7 Rs.
(excluding Service Tax)
Final Premium under expiring policy (as on the date,
8 Rs.
please specify) (excluding service tax)
Version 2
Format for Business Acceptance / Quote - GMC
36-45
46-55
56-65
66-70
71-75
76-80
Total
Sum Insured Per Person/ Per Family (Rs.)
If different sum insured is opted for different catogories of
9
the employees, please provide the details in the sheet 2
attached
IX Claims details under the expiring policy as on ____________________ (please specify the date)
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Star Health and Allied Insurance Company Limited
No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600034
Phone: 044 - 28288800 Fax - 044 - 28260062, Website : www.starhealth.in
Version 2
Format for Business Acceptance / Quote - GMC
10 (b) If yes, Please specify
11 (a) Corporate Buffer Aomunt if any
11 (b) Maximum sum insured under Corporate Buffer per family
Maximum number of cases during the policy period for
11 ( c)
Corporate Buffer if same is to be capped
12 (a) Room Rent Limits - for Normal / ICU
12 (b) Room Rent Limits - for ICU
13 Pre Hospitalisation
14 Post Hospitalisation
15 Copay
16 Any other requirement of cover. (Pl. specify)
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 amd complete in all respects to the best of my knowledge and that I/We am/are authorized to
propose on behalf of these persons.
Date :
Place :
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