Primary insured details
Date of birth *
Gender *
PAN number
Whether suffering from pre-existing disease(PED)? *help
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Upload a photograph of the person to be insured *
Please upload the passport size (preferred) photograph while proceeding to buy policy.
Plan details
Plan *
Sum insured *
Do you want to extend the coverage for Personal Accident? *
TIP: You can extend the coverage for Personal Accident also with an additional premium of Rs 60 only(per lakh/ per member)
Name of the nominee for primary insured *
Relationship with the nominee *
Start date *
End date
Do you want to avail Life Hardship Survival Benefit? *help
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Do you wish to insure your spouse?
Do you wish to insure your dependent children?
Do you wish to insure your father?
Do you wish to insure your mother?
Do you wish to insure your father-in-law?
Do you wish to insure your mother-in-law?
Name and address of family physician  help
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Name of family physician
Address of family physician
Do you wish to opt for TPA services?
Tip: You get 5% discount if you opt out of TPA(Third Party Administrator) Service
1. 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.
2. 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.
3. 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.
4. I declare and consent to the company seeking medical information from any doctor or from a hospital who at any time 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.
5. I 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 Governmental and/or Regulatory authority.
Select your branch office  help
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OICL Office State *
City/Town *
Branch/Office *
Please select a role to continue
Whether any agent is involved for this proposal?
* If 'NO' is selected, the policy will be issued under code of Development Officer without an Agent.
Pre Existing Diseases
Since you are suffering from Pre Existing Disease(PED), you are requested to contact the nearest OICL office for policy issuance.