Proposer Details

Name Mr. SUKHPAL SINGH(Married) Address HOUSE NO 13, SECTOR 41 A, CHANDIGARH,

Member Information
Birth Date (DD­
Name Height(In) Weight(Kgs) Gender Proposer MaritalStatus Nominee Relationship with Nominee Age Occupation BMI
MM­YYYY)

Relation
SUKHPAL SINGH 68 85 Male 03­07­1983 Yes Married MANDEEP KAUR Wife 40 Salaried 28.4927040442316
Self

Relation
MANDEEP KAUR 63 50 Female 13­08­1986 ­­ Married MANDEEP KAUR Wife 37 Salaried 19.5263681028748
Spouse

Relation
HARSUKHMAN SINGH 54 40 Male 07­12­2010 ­­ Single MANDEEP KAUR Wife 13 Student 21.2620452675748
Son

Booking Information
Ref ID Insurer Plan Sum Insured Term Premium Proposal No Payment Status
0 Niva Bupa (formerly known as Max Bupa) ReAssure 2.0 Platinum (Direct) 750000 1 19026 NA

Medical Information
Member Name Question Answer Description Policy Type
Other than common cold, flu, infections, minor injury or other minor ailments; have you ever been
hospitalized for more than 5 days, undergone / advised to undergo any surgical procedures, or taken
SUKHPAL SINGH No Health Policy
any medication/ had any symptoms for more than 14 days? Medication is including but not limited to
inhalers, injections, oral drugs and topical applications.
SUKHPAL SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
Have you ever had adverse findings to any diagnostic tests or investigations such as Thyroid Profile,
SUKHPAL SINGH Lipid Profile, Treadmill test, Angiography, Echocardiography, Endoscopy, Ultrasound, CT Scan, MRI, No Health Policy
Biopsy and FNAC?
SUKHPAL SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
SUKHPAL SINGH Do you have diabetes or high blood pressure? No Health Policy
SUKHPAL SINGH Diabetes No Health Policy
SUKHPAL SINGH Are you on insulin ? No Health Policy
SUKHPAL SINGH HbA1c Level No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
SUKHPAL SINGH High Blood Pressure No Health Policy
SUKHPAL SINGH BP Level Systolic No Health Policy
SUKHPAL SINGH BP Level Diastolic No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
SUKHPAL SINGH Have you ever been diagnosed or treated for any genetic / hereditary disorders or HIV / AIDS? No Health Policy
SUKHPAL SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
SUKHPAL SINGH Have you ever been diagnosed or treated for any mental/ psychiatric disorders? No Health Policy
SUKHPAL SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
SUKHPAL SINGH Onset date No Health Policy
SUKHPAL SINGH Medicine Name No Health Policy
SUKHPAL SINGH Dosage No Health Policy
SUKHPAL SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
SUKHPAL SINGH Treating doctor’s name & contact details No Health Policy
SUKHPAL SINGH Does any of the applicants Smokes Cigarettes/Bidi/Cigar No Health Policy
SUKHPAL SINGH Please specify consumption per day No Health Policy
SUKHPAL SINGH Does any of the applicants takes alcohol No Health Policy
SUKHPAL SINGH Is Daily Drinker No Health Policy
SUKHPAL SINGH Please specify ml per week No Health Policy
SUKHPAL SINGH Does any of the applicants Chew tobacco/Gutkha/Pan Masala No Health Policy
SUKHPAL SINGH Please specify number of pouches per day No Health Policy
SUKHPAL SINGH Qualification Yes Post­Graduate Health Policy
Has any proposal for life, health, hospital daily cash, Personal Accident or critical illness insurance on the
SUKHPAL SINGH life of the applicant ever been declined, postponed, loaded or subjected to any special conditions such No Health Policy
as exclusions by any insurance company?
SUKHPAL SINGH Are you a politically exposed person (PEP) or a close relative of PEP? No Health Policy
Other than common cold, flu, infections, minor injury or other minor ailments; have you ever been
hospitalized for more than 5 days, undergone / advised to undergo any surgical procedures, or taken
MANDEEP KAUR No Health Policy
any medication/ had any symptoms for more than 14 days? Medication is including but not limited to
inhalers, injections, oral drugs and topical applications.
MANDEEP KAUR Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
Have you ever had adverse findings to any diagnostic tests or investigations such as Thyroid Profile,
MANDEEP KAUR Lipid Profile, Treadmill test, Angiography, Echocardiography, Endoscopy, Ultrasound, CT Scan, MRI, No Health Policy
Biopsy and FNAC?
MANDEEP KAUR Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
MANDEEP KAUR Do you have diabetes or high blood pressure? No Health Policy
MANDEEP KAUR Diabetes No Health Policy
MANDEEP KAUR Are you on insulin ? No Health Policy
MANDEEP KAUR HbA1c Level No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
MANDEEP KAUR High Blood Pressure No Health Policy
MANDEEP KAUR BP Level Systolic No Health Policy
MANDEEP KAUR BP Level Diastolic No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
MANDEEP KAUR Have you ever been diagnosed or treated for any genetic / hereditary disorders or HIV / AIDS? No Health Policy
MANDEEP KAUR Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
MANDEEP KAUR Have you ever been diagnosed or treated for any mental/ psychiatric disorders? No Health Policy
MANDEEP KAUR Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
MANDEEP KAUR Onset date No Health Policy
MANDEEP KAUR Medicine Name No Health Policy
MANDEEP KAUR Dosage No Health Policy
MANDEEP KAUR Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
MANDEEP KAUR Treating doctor’s name & contact details No Health Policy
MANDEEP KAUR Does any of the applicants Smokes Cigarettes/Bidi/Cigar No Health Policy
MANDEEP KAUR Please specify consumption per day No Health Policy
MANDEEP KAUR Does any of the applicants takes alcohol No Health Policy
MANDEEP KAUR Is Daily Drinker No Health Policy
MANDEEP KAUR Please specify ml per week No Health Policy
MANDEEP KAUR Does any of the applicants Chew tobacco/Gutkha/Pan Masala No Health Policy
MANDEEP KAUR Please specify number of pouches per day No Health Policy
MANDEEP KAUR Qualification Yes Graduate Health Policy
Has any proposal for life, health, hospital daily cash, Personal Accident or critical illness insurance on the
MANDEEP KAUR life of the applicant ever been declined, postponed, loaded or subjected to any special conditions such No Health Policy
as exclusions by any insurance company?
MANDEEP KAUR Are you a politically exposed person (PEP) or a close relative of PEP? No Health Policy
Other than common cold, flu, infections, minor injury or other minor ailments; have you ever been
hospitalized for more than 5 days, undergone / advised to undergo any surgical procedures, or taken
HARSUKHMAN SINGH No Health Policy
any medication/ had any symptoms for more than 14 days? Medication is including but not limited to
inhalers, injections, oral drugs and topical applications.
HARSUKHMAN SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
Have you ever had adverse findings to any diagnostic tests or investigations such as Thyroid Profile,
HARSUKHMAN SINGH Lipid Profile, Treadmill test, Angiography, Echocardiography, Endoscopy, Ultrasound, CT Scan, MRI, No Health Policy
Biopsy and FNAC?
 HARSUKHMAN SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
HARSUKHMAN SINGH Do you have diabetes or high blood pressure? No Health Policy
HARSUKHMAN SINGH Diabetes No Health Policy
HARSUKHMAN SINGH Are you on insulin ? No Health Policy
HARSUKHMAN SINGH HbA1c Level No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
HARSUKHMAN SINGH High Blood Pressure No Health Policy
HARSUKHMAN SINGH BP Level Systolic No Health Policy
HARSUKHMAN SINGH BP Level Diastolic No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
HARSUKHMAN SINGH Have you ever been diagnosed or treated for any genetic / hereditary disorders or HIV / AIDS? No Health Policy
HARSUKHMAN SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
HARSUKHMAN SINGH Have you ever been diagnosed or treated for any mental/ psychiatric disorders? No Health Policy
HARSUKHMAN SINGH Details of symptom(s) or investigation(s) or diagnosis or procedure/surgery undergone No Health Policy
HARSUKHMAN SINGH Onset date No Health Policy
HARSUKHMAN SINGH Medicine Name No Health Policy
HARSUKHMAN SINGH Dosage No Health Policy
HARSUKHMAN SINGH Current Status (e.g. Complete/Partial Recovery or Ongoing Treatment) No Health Policy
HARSUKHMAN SINGH Treating doctor’s name & contact details No Health Policy
HARSUKHMAN SINGH Does any of the applicants Smokes Cigarettes/Bidi/Cigar No Health Policy
HARSUKHMAN SINGH Please specify consumption per day No Health Policy
HARSUKHMAN SINGH Does any of the applicants takes alcohol No Health Policy
HARSUKHMAN SINGH Is Daily Drinker No Health Policy
HARSUKHMAN SINGH Please specify ml per week No Health Policy
HARSUKHMAN SINGH Does any of the applicants Chew tobacco/Gutkha/Pan Masala No Health Policy
HARSUKHMAN SINGH Please specify number of pouches per day No Health Policy
HARSUKHMAN SINGH Qualification Yes Non­matric Health Policy
Has any proposal for life, health, hospital daily cash, Personal Accident or critical illness insurance on the
HARSUKHMAN SINGH life of the applicant ever been declined, postponed, loaded or subjected to any special conditions such No Health Policy
as exclusions by any insurance company?
HARSUKHMAN SINGH Are you a politically exposed person (PEP) or a close relative of PEP? No Health Policy

12/18/2023 12:15:32 PM