Annual Premium (All currency values in AED)

Transcription

1 Annual Premium (All currency values in AED) Age Band Bronze Silver Gold Platinum Diamond yrs 840 1,040 1,270 1,520 1, yrs 1,050 1,290 1,640 1,960 2, yrs 1,580 1,960 2,540 3,050 3,420 Over 80 yrs 2,160 2,680 3,480 4,170 4,670 *Proposer s PA will be paid as per the higher value of the sum insured opted by the insured. For renewals beyond 80 years, the premium has to be loaded by 3% of the expiring policy premium for every renewal.

2 Parents Health Benefits Schedule (All claims settlements in INR* only) Benefits Bronze Silver Gold Platinum Diamond Sum Insured 3 Lakhs 4 Lakhs 5 Lakhs 7.5 Lakhs 10 Lakhs In-Patient Hospitalisation Covered Room Rent - limit per day up to 1% of the sum insured - max. INR* 6,000 ICU charges, Drugs/Consumables - limit per day Anaesthesia, Blood, Oxygen, Operation Theatre charges Ambulance sub limit - per incidence / per policy period Pre-Hospitalization Post-Hospitalization Dental & Ophthalmic Hospital Cash Health Checkup No limit No limit INR* 2,500 / INR* 5, days 30 days Covered after every block of 2 years for sum insured 5,00,000 and above, up to maximum of INR* 5,000 Per day INR* 1,000 for hospital stay exceeding 6 consecutive days with an annual limit of 60 days Covered after every block of 4 claim free years under the policy, up to a maximum of INR* 5,000 Co-Payment Age at entry 51 to 60 years -10%; Age at entry above 60 years - 20% Day-care Treatments Waiting period for specific diseases Waiting period for pre-existing diseases Cataract per policy period with waiting period of 24 months PA One way Airticket Policy for 2 years 405 different treatments covered 24 months 36 months 18,000 20,000 21,500 23,000 25,000 World Wide death only cover for the proposer Only for the proposer if any of the insured person/s is admitted in hospital for a continuous period of not less than 7 days for Heart, Stroke, Cancer, Disease of Lungs, Liver Disease, Renal Disease / accidents resulting in grevious injury, cost of airticket up to INR* 10,000. Policy for 2 years with 7.5% discount provided 2 year premium is paid upfront Sublimits Bronze Silver Gold Platinum Diamond Heart Disease / Stroke / Cancer Renal / Liver / Lung diseases 2 Lakhs 2.25 Lakhs 2.75 Lakhs 5 Lakhs 6.5 Lakhs Other Major Diseases 1.5 Lakhs 2 Lakhs 2.25 Lakhs 4 Lakhs 5 Lakhs

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4 Please complete this form using block CAPITALS and by ticking the relevant boxes. Please retain a copy of this proposal form and other correspondences with us for your future reference. Applicant s Details Name (as in passport) First name Family name: Passport no. Company Date of birth: Designation: Address Building: Street: Area: P. O. Box: Emirate: Contact details* Mobile: Plan Sum Insured Options Bronze - INR* 3 Lakhs Silver - INR* 4 Lakhs Gold - INR* 5 Lakhs Platinum - INR* 7.5 Lakhs Diamond - INR* 10 Lakhs List of Insured Persons Name Relation Sex Date of birth Age Sum insured Premium Total Contact Details* of Insured Persons in India Address of parents: District: State: Pin Code: Contact details:

5 Beneficiary (For Applicant s Personal Accident Cover) Name Relation Share (%) Pre-Existing Medical Conditions of Insured Person/s Name of Insured Person Diabetes Millitus BP Cholesterol Heart Disease Stroke Cancer Chronic Kidney/Liver Parkinson s Alzheimers Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Any other disease? If yes, please specify: Payment I authorise to charge the premium below to my credit card account for this insurance policy. Also, I authorize to debit my card every year for renewal of my policy, until I cancel it by written / mail notification at least 30 days in advance of the intended date of cancellation. Master card Visa card Expiry date m m y y Credit card no. Cheque Date m m y y Amount AED Declaration I hereby declare and warrant on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects. I agree that this proposal and the declarations shall be the basis of the contract between me and all persons to be insured and Oman Insurance Company P.S.C. I declare to the best of my knowledge that the above answers whether in my handwriting or not are true and complete and agree that they shall be the basis of contract of insurance. I understand that signing this Proposal Form does not bind the Proposer or the Insurers to complete this insurance. I understand that this application is only for Non-Resident Indians. I agree that I have not concealed any material fact (a material fact is one that could influence the assessment of the application) and understand that the failure to disclose a material fact may invalidate the contract since inception. A photocopy, scan copy, or fax copy of this authorisation shall be suitable evidence of this authority and legally original. Date d d m m y y y y Proposer s signature Agent Details Insurance agent Name: Code: Agency branch

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