Change Request form
Policy Number:
Name of Proposer:
Please tick the appropriate box and fill the details in the corresponding section:
1. Change in Address 2. Change in Tenure 3. Change in Sum Insured 4. Member Addition/ Deletion 5. Change in Product 6. Others
I want to opt for a) Protector Rider^ b) Individual Personal Accident Rider* c) Hospital Daily Cash Rider^ with Sum Insured: ` 1000 per day ` 2000 per day ` 3000 per day
* Sum Insured under Individual Personal Accident rider will be 5 (five) times the Sum Insured of Optima Restore (Base Plan) upto a maximum of Rs. 1 Crore and this rider will be offered only to
the Proposer. ^Protector Rider and Hospital Daily Cash Riders will be offered on individual sum insured basis if the base plan is on individual sum insured basis or floater sum insured basis if the
base plan is on floater sum insured basis. Protector Rider and Hospital Daily Cash Riders will be available on all or none basis.
I want to add a to my health Insurance. Yes No
1. New Address (Address proof to be enclosed)
Name : (Mr./ Ms./ Mrs.)
Address :
City/ Town :
District : State :
Pin Code : Mobile :
Telephone : E Mail :
2A. I want to opt for 2-year plan 2B. I want to opt for 1-year plan
3. Change in Sum Insured
Name of Insured:
Existing Sum Insured: Desired Sum Insured:
4. Member Deletion/ Addition
Name of Insured:
Date of Birth D D M M Y Y Y Y Gender Male Female
Relationship with proposer:
Reason for deletion:
For addition of any individual, fresh proposal form should be filled.
5. Change in Product
Name of Insured:
Existing Product: Desired Product:
Desired Sum Insured/ Deductible
Desired Plan Variant
(in case of Optima Plus product):
Individual/ Floater Height/ Weight*
* To be filled only incase Insured shifted from Optima Cash Product
Note: Please enclose an additional sheet for change in sum insured/ change in product for more than one member
Health Status Declaration : Post commencement of your insurance policy with us, did you suffer from or are currently suffering from or have developed any disease/
illness/ injury or accident/ medical condition other than common cold or fever? Yes No
If answer is yes, please provide all the relevant documents/ information including but not limited to Doctors prescription, Medical Test Reports etc.
Please note: Any Non Disclosure or Incomplete/ incorrect/ partially correct information may lead to repudiation of claim or cancellation of policy as per policy terms and conditions.
If Sum Insured Change is desired for more than one member, please use additional sheet to give information.
(Applicable for Easy Health, Optima Restore, Optima Plus, Maxima, Optima Senior, Optima Cash, Individual Personal Accident Product.)
6. Others, please furnish details:
we accept and agree that:
1. I/ We may have to undergo fresh pre policy health checkup as a result of opting for (i) increase in sum insured and/or (ii) addition of critical advantage rider/ critical illness rider and/ or (iii)
Addition of insured member/ change in product.
2. I/ We shall comply with any other additional requirements including payment of additional premium towards risk loading, if any, within 7 days from the date of such written communication
received from HDFC ERGO Health Insurance Ltd.
3. I/ We authorize HDFC ERGO Health Insurance Ltd. to renew the Existing Policy under its existing terms and conditions if I/ We fail to comply with either of the above stipulations”
4. I hereby declare and warrant that on my behalf and on behalf of all the insured that all the information provided above are true and complete in all respect and no other information which is
relevant in the context has been supressed.
Signature of Proposer/ Policy Holder: Date:
Certification in case the Proposer has signed in vernacular : (The below must be witnessed by someone other than the agent/ employee of the company)
The contents of this form and its particulars have been explained by me in vernacular to the Executant.
Signature of the Proposer: Signature of the Witness:
Name of Witness:
Address:
Contact Number:
HDGC ERGO Health Insurance Ltd. reserves the right to accept/ reject any changes requested. Certain changes may require additional premium, letters to this effect would be sent
Enclosures: (if any) 1. 2. 3.
We would be happy to assist you. For any help contact us at: E-mail: [email protected] Toll Free: 1800 102 0333
HDFC ERGO Health Insurance Limited (Formerly known as Apollo Munich Health Insurance Company Limited.) • Central Processing Centre: 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III,
Gurugram-122016, Haryana • Corp. Off. 1st Floor, SCF-19, Sector-14, Gurugram-122001, Haryana • Registered Off. 101, First Floor, Inizio, Cardinal Gracious Road, Chakala, Opposite P & G Plaza, Andheri (East),
Mumbai, Maharashtra 400069 India • Tel: +91-124-4584333 • Fax: +91-124-4584111 • Website: www.hdfcergohealth.com • Email: customerservice hdfcergohealth com • For more details on risk factors, terms
and conditions please read sales brochure carefully before concluding a sale.•Tax laws are subject to change • IRDAI Registration Number - 131 • CIN: U66030MH2006PLC331263
