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    New Born Baby Form

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    rafeekmekgce
    Mohamed Rafeek Mohamed Ilyas requests inclusion of his newborn daughter, Aadhila, born on August 28, 2023 at Nimal Nursing Home in Thuraiyur, under his existing health insurance policy with Star Health and Allied Insurance Co. Ltd. Aadhila experienced no complications during her birth by C-section and has no known medical illnesses or conditions. Rafeek declares Aadhila is currently healthy and provides consent for the insurer to access her medical information for underwriting and claims purposes. He understands Aadhila will be covered under the current policy without additional premium and subsequent renewals upon payment of premium.

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    New Born Baby Form

    Uploaded by

    rafeekmekgce
    98 views1 page
    Mohamed Rafeek Mohamed Ilyas requests inclusion of his newborn daughter, Aadhila, born on August 28, 2023 at Nimal Nursing Home in Thuraiyur, under his existing health insurance policy with Star Health and Allied Insurance Co. Ltd. Aadhila experienced no complications during her birth by C-section and has no known medical illnesses or conditions. Rafeek declares Aadhila is currently healthy and provides consent for the insurer to access her medical information for underwriting and claims purposes. He understands Aadhila will be covered under the current policy without additional premium and subsequent renewals upon payment of premium.

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    Original Title

    New born baby form (1)

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    Mohamed Rafeek Mohamed Ilyas requests inclusion of his newborn daughter, Aadhila, born on August 28, 2023 at Nimal Nursing Home in Thuraiyur, under his existing health insurance policy with Star Health and Allied Insurance Co. Ltd. Aadhila experienced no complications during her birth by C-section and has no known medical illnesses or conditions. Rafeek declares Aadhila is currently healthy and provides consent for the insurer to access her medical information for underwriting and claims purposes. He understands Aadhila will be covered under the current policy without additional premium and subsequent renewals upon payment of premium.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    98 views1 page

    New Born Baby Form

    Uploaded by

    rafeekmekgce
    Mohamed Rafeek Mohamed Ilyas requests inclusion of his newborn daughter, Aadhila, born on August 28, 2023 at Nimal Nursing Home in Thuraiyur, under his existing health insurance policy with Star Health and Allied Insurance Co. Ltd. Aadhila experienced no complications during her birth by C-section and has no known medical illnesses or conditions. Rafeek declares Aadhila is currently healthy and provides consent for the insurer to access her medical information for underwriting and claims purposes. He understands Aadhila will be covered under the current policy without additional premium and subsequent renewals upon payment of premium.

    Copyright:

    © All Rights Reserved
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    You are on page 1of 1

    Draft letter to be obtained for inclusion of New Born Baby

    From

    MOHAMED RAFEEK MOHAMED ILYAS


    2/122, AMBALAKAR STREET
    PERUMAL PALAYAM
    THURAIYUR, TRICHY - 621008

    To
    Star Health and Allied Insurance Co. Ltd.,

    Dear Sir/Madam,

    Reg : Inclusion of new born baby under policy no: _P/700002/01/2023/058430 Customer ID 8231458-1
    I request you to kindly include new born baby under the policy no.___ P/700002/01/2023/058430 ____________________

    Details of new born baby as follows :-

    Name of the new born : AADHILA


    Gender : FEMALE
    Date of Birth : 28/08/2023
    Place of Birth : THURAIYUR
    Name of the hospital : NIMAL NURSING HOME, THURAIYUR
    The health history of the new born baby as follows :-

    1.Complications following birth (Yes/No) No complications, Birth was by C-section for the reason that uterus
    (If yes, please furnish details) mouth was not fully opened.

    2. Intensive care treatment required at birth / No


    immediately after birth (Yes/No)
    (If yes, please furnish details)
    3.Any medical illnesses suffered (Yes/No) No
    (If yes, please furnish details)

    4. Congenital illness / conditions identified, if


    No
    any, whether internal or external
    5. Maternity cover has undergone with our
    No
    star health insurance.(Yes/No)

    I hereby declare that above said new born baby is currently healthy and does not suffer from any illness and/or health
    condition(s).

    I further declare that the above particulars given by me are true and complete in all respects, to the best of my knowledge and
    belief, and that I am authorized to propose for insurance coverage of the new born baby. I declare and consent to the company
    seeking medical information from any doctor or from a hospital who at anytime has attended on the new born baby. I authorize
    the company to share information pertaining to the new born baby, the medical records for the sole purpose of proposal
    underwriting and/or claims settlement and with any Government and/or Regulatory authority.

    I understand that this new born baby will be covered under the current policy, subject to your approval, without additional
    premium, and it will continue to be covered under the subsequent renewal policy, on payment of appropriate premium.

    Signature : MOHAMED RAFEEK MOHAMED ILYAS

    Place: THURAIYUR
    Date: 08/10/2023

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