Proposal Form No.
: 3250523637 ManipalCigna Health Insurance Company Limited
(Formerly known as CignaTTK Health Insurance Company Limited)
Corporate Office: 401/402, Raheja Titanium, Western Express Highway,
Goregaon (E), Mumbai - 400063. IRDAI Registration No. 151.
Call (Toll Free): 1800-102-4462 Visit: [Link]
E-mail: customercare@[Link] CIN No.: U66000MH2012PLC227948
MANIPALCIGNA SARVAH
PORTABILITY FORM
PART I
1. PERSONAL DETAILS OF POLICYHOLDER/ INSURED:
Name of the Policy Holder/ Insured: Krishnegowda B C
Date of Birth: 08/12/1985
Email: Manjulakrishnahsk@[Link]
Address: Hoskote Talluku Bheemakkanahalli , Begur
City: Bangalore State: Karnataka
Pin code: 562122
2. DETAILS OF EXISTING INSURER:
Name of the Product: ReAssure 2 0
Sum Insured: 1000000
Cumulative Bonus: 0
Add-ons/riders taken: NO
Policy Number: 33996277202400
3. DETAILS OF THE PROPOSED INSURANCE:
i. Name of the product proposed/intend to take: SARVAH
ii. Sum Insured Proposed: 1000000
iii. Whether Cumulative Bonus to be converted to an enhanced sum insured: NO
Reason(s) for Portability: Best Plan
No. of family members to be included in the policy to be ported: 4
ENCLOSURE: PHOTOCOPY OF THE EXISTING POLICY DOCUMENTS
Date: 10-05-2025
Signature of the Policy Holder
PART II
Whether the PED exclusions/ time bound exclusions have longer exclusion period than the existing policy: (Please indicate Yes/ No) Yes No
• 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 Policy Holder
PORTABILITY FORM (ANNEXURE)
SECTION A. PERSONAL DETAILS OF POLICYHOLDER/ INSURED:
i) Proposal Number 3250523637
ii) Existing Insurance Details
1. Please indicate whether covered under: Group Policy Retail Policy
2. Have you extended your current policy on short term basis? Yes No
Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8
Name Krishnegowda Lalith Nandan Rishetha G Vijaya
Policy 1 DOJ 11/05/2024 11/05/2024 11/05/2024 11/05/2024
Sum Insured 1000000 1000000 1000000 1000000
Policy Type MEDICLAIM MEDICLAIM MEDICLAIM MEDICLAIM
Cumulative Bonus
Name
Policy 2 DOJ
Sum Insured
Policy Type
Cumulative Bonus
Name
Policy 3 DOJ
Sum Insured
Policy Type
Cumulative Bonus
Name
Policy 4 DOJ
Sum Insured
Policy Type
Cumulative Bonus
DOJ - Date of joining 11/05/2024
iii) Pre- Existing Details
Pre-exiting details for Proposed Insured Persons (The below section is mandatory. Please fill in NIL where the section is not applicable.)
[Link] Name PED declared No. of years of Continuous Waiting period completed Waiting period remaining
Cover
Insured 1 Krishnegowda NA
Insured 2 G Vijaya NA
Insured 3 Lalith Nandan NA
Insured 4 Rishetha NA
Insured 5
Insured 6
Insured 7
Insured 8
Documents to be provided:
1. Policy Schedule for the previous year(s) as available. 2. Renewal notice for the expiring policy
Acceptance of Portability is subject to the following
1. Application for Portability to ManipalCigna Health Insurance Company Limited is made at least 45 days before the policy renewal date of current insurance policy
2. Availability of relevant medical / Claim history from previous insurer.
3. Risk acceptance by Underwriting on evaluation of Proposal form or any Pre Policy Health Check up/ additional information.
4. Acceptance of revised offer (if any) must be provided within 7 days of intimation.
5. The company shall not be liable if the application is rejected due to non-adherence to the above guidelines.
Declarations
I understand that my application for portability is being processed and some details are being sought from my current Insurer prior to acceptance of proposed risk. In absence of receipt of the
same before expiry of my existing policy, I authorize ManipalCigna Health Insurance Company Limited to process my application based on the information furnished along with the supporting
documents provided herein. However, if any variance is subsequently found, ManipalCigna Health Insurance Company Limited shall at its discretion cancel/ modify my coverage through
appropriate endorsement and/or take these into consideration while adjudicating any claims under this policy. I also understand that I can extend my existing policy with current insurer to
ensure no break in coverage and shall intimate the same in writing to ManipalCigna Health Insurance Company Limited in case of no written communication regarding acceptance of proposed
risk on or before expiry of my existing policy.
Date: 2025-05-10