Health Top-Up Policy

BOOST YOUR HEALTH COVER

Add affordable extra cover above your existing base health policy

Proposer details

Full name (Proposer) *

Mobile number *

Alternate phone

Date of birth

Gender

Occupation

PAN number

Address

City

State

Pincode

Cover details

Tell us about your existing base policy and the extra cover you need.

Current insurer (base policy)

Current base cover (₹) *

Sum insured of your existing health policy

Required top-up cover (₹) *

Extra cover you want above the base

Deductible (₹)

Amount you'll pay before top-up activates

Policy term (years)

Members to be insured

Add every person you want covered under this top-up.

Member 1

Should the proposer be insured? (auto-fills name, DOB, gender, relation)

Full name

Relation to proposer

Date of birth

Gender

Height (cm)

Weight (kg)

Pre-existing conditions (if any)

Medical & policy history

Does any member have pre-existing illness or chronic condition?

Yes

Do you already have any top-up / super top-up policy?

Yes

Bank details

Required for premium auto-debit and claim settlement.

Bank name *

IFSC code *

Account number *

Notes for our policy desk

Declaration

I declare that the information provided is true and complete to the best of my knowledge. I authorise Manoj Kumar Associates to contact me regarding policy processing.