Portability Form

National Insurance Company Limited  Insurance Company Limited :

Portability Form

PART- I                                                                                                Agent Code

Name of the Policyholder / insured (s)
Date of Birth/Age :
Telephone No :
Email ID :

Details of existing insurer

Name of the product :	Individual Mediclaim Policy
Sum Insured :
Policy number :
Add-ons/riders taken :
Cumulative Bonus :
Policy Expiry Date
Member details (Pl fill table below)
Have you extended your current policy on short term basis : Yes  /No
Short Term Expiry Date

*Non Mandatory fields , to be provided member wise if applicable

Details of the insurance intend to be taken :

Name of the product proposed/intend to take
Sum Insured Proposed
Maternity Benefit Limit
Maternity Waiting  Period
Number of family members to be included in the policy to be ported :
Whether Cumulative Bonus to be converted to an enhanced sum insured : Yes  /No 
Reason(s) for Portability :

Details of existing insurance policy

Member name	Member ID	DOB/Age	No. of years of continous coverage	Sum Insured	Cumulative Bonus	Member PAN*	Member UID*	Member Ref Key*

*Non Mandatory fields , to be provided member wise if applicable

Part II

Member name	Whether the PED exclusions/ time bound exclusions have longer exclusion period than the existing policy : 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 policyholder _____________________________________

 Date

General Conditions for Portability:

Portability benefits are subjected to the receipt and evaluation of the  following documents in addition to portability form :

•         A  proposal form of Max Bupa with questions relating to previous/existing health insurance details duly filled in

•         Photocopy of the existing policy documents

•         Copy of the Last 4 years Policy Schedule required ( if applicable ) issued by the previous Insurer OR Renewal Notice

•         Self-declaration by customer regarding no claims made

•         If there is a claim in existing policy, then discharge summary, investigation and follow up report copies

•         If there is a past medical history, then consultation papers, prescription, investigation, treatment and report copies

The acceptance of portability is subject to the following :

·        The application for portability should be provided 45 days prior to the date of expiry of the previous Health Insurance Policy to avail a continuity benefit.

·        MBHI will follow a medical underwriting risk assessment process and as part of this process, and the proposed insured/s  might be required to go through a medical test.

·        MBHI will also collect the claim information from the previous insurer  

·        While we process the request for portability and in case your existing insurance policy coverage is expiring shortly, the proposed insured may opt for a short period policy with the existing insurer to ensure continuity benefit.

·        MBHI will not have any liability till such time policy is ported with MBHI.

MBHI reserves the right to accept or reject any application basis the MBHI applicable guidelines