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Health Insurance Portability Form

The document is a portability form for transferring an insurance policy to a new insurer. It requests information about the existing policyholder and policy to be transferred, including name, date of birth, address, policy details, sum insured, riders, and reason for portability. It also requests details about the proposed new policy, including product name and sum insured. The policyholder must provide consent if the new policy has longer exclusion periods than the previous one.

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VeejhayCShaah
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439 views2 pages

Health Insurance Portability Form

The document is a portability form for transferring an insurance policy to a new insurer. It requests information about the existing policyholder and policy to be transferred, including name, date of birth, address, policy details, sum insured, riders, and reason for portability. It also requests details about the proposed new policy, including product name and sum insured. The policyholder must provide consent if the new policy has longer exclusion periods than the previous one.

Uploaded by

VeejhayCShaah
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Portability Form

Part-I
Name of the Policyholder / insured (s)

Date of Birth/Age

Address of the policyholder/insured

Details of existing insurer

Name of the product

Sum Insured

Cumulative Bonus

Add-ons/riders taken

Policy number

Details of the proposed insurance

Name of the product proposed/intend to take


Sum Insured Proposed

Whether Cumulative Bonus to be converted to


an enhanced sum insured
Reason(s) for Portability

No. of family members to be included in the

policy to be ported:

Enclosure: Photocopy of the existing policy documents

Date: Signature of the

policyholder
PART –II
1. Whether the PED exclusions / time bound exclusion have longer exclusion period than
the existing policy: (Please indicate Yes / NO):
2. If yes, please give written consent to the declaration below:

“I am aware that the waiting period for the following disease(s)/treatment(s) is …..
days/years more than the previous policy terms. I hereby agree to observe the additional
waiting period for the following disease(s)/treatment(s)

Signature of the
policyholder

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