Senior Citizen Health Insurance Proposal Form
1. Proposer Details
Full Name
Relationship to Insured
Address
Contact Number
Email
Nominee Name
2. Insured Person(s) Details
Full Name
Date of Birth
Gender
Male
Female
Other
Occupation
Height (cm)
Weight (kg)
Pre-existing Diseases
3. Policy Details
Sum Insured
Policy Period
4. Medical History
Details of Any Past/Current Illness
Hospitalization in Last 4 Years
5. Other Details
Existing Health Insurance
Any Additional Information