GROUP POLICY PORTAL

Product Details

Product Type

Family Composition

Kindly provide below Health Declaration before Purchasing Policy I have read all Terms & Conditions offered by insurer

Health declaration of Self

1. Are you Suffering from or suffered from Diabetes / High Blood pressure / Complaints related to Heart

2. Are your suffering or have suffered from Cancer

3. Do you Chew Tobacco or use tobacco daily

4. Do You smoke more than 2 cigarettes per Day /Do you drink alcohol more than 30 ml per Day

Policy(Certificate) Details

Risk Start Date

Risk End Date

Date Of Birth (Highest Age of Self/Spouse)

Insured Details

Self First and Middle Name

Self Last Name

Self Date Of Birth

Self Gender

Self Occupation

Self Nominee name

Self Nominee Relation

Address 1

Address 2

State

City

Pincode

Mobile

Spouse First and Middle Name

Spouse Last Name

Spouse Gender

Spouse Date Of Birth

Spouse Occupation

Spouse Nominee name

Spouse Nominee Relation

Declarations & Consent

I am RuPay card holder / UPI user
I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above 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.
The above Health declaration is correct to the best of my knowledge, I hereby give undertaking that if any of the answers found to be false later or during the claim, the company shall have full rights to repudiate the claim & cancel my policy.
I hereby give my consent to send my policy and health cards in digital format only.
I hereby authorize Universal Sompo General Insurance Company to contact me through physical, electronic or telecommunication means from time to time in regards to my policy and any other offerings and services. I agree that this consent will override my NDNC registration