Group Health Proposal Form

Date of Proposal

Date

Agent / Broker Name*

Email*

example@example.com

Reference No.

Name of Company*

Address

Contact person Name*

Contact Number*

Nature of Business*

Total Number of Active Employees*

No. of employees participating*

Retirement Age*

Over age Employee Cover*

Basis of Takaful Cover*

Compulsory SchemeNon-Compulsory SchemeContributory SchemeNon-Contributory Scheme

Max Number of Spouse per Employee

Max Number of Children per Employee

FirstLast

Name of Existing Insurer/Takaful Co.

Policy Expiry Date

Date

Benefits Opted

Claim Experience

	Policy Year	No. of lives at inception	No. of lives at expiry	No. of Hospitalization claims	Amount of Hospitalization Claims	No. of Maternity Claims	Amount of Maternity Claims
1
2
3
4

Last year Benefits

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Upload Claims Details

Browse Files

Multiple files can be uploaded

No. of Options required*

Required Benefits Option 1*

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Required Benefits Option 2

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Required Benefits Option 3

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Required Benefits Option 4

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Required Benefits Option 5

	Plan A	Plan B	Plan C	Plan D	Plan E	Plan F
Hospitalization Limit
Room Limit
Maternity (Normal)
Maternity (C-Sec)
OPD

Any Other information/ Instructions

Upload Member Data *

Browse Files

Multiple files can be uploaded

Upload Others*

Browse Files

Multiple files can be uploaded

Attach Client request for Proposal*

Browse Files

Email/Letter

Document Check list

I/We hereby confirm that the *material facts contained in this proposal form are true and correct to the best of my/our knowledge and belief and I/We have not concealed, misrepresented or misstated any material fact. I/We further undertake to inform the Company of any material alterations to these facts occurring during the currency of this Policy within 7/10 days from the date of occurrence of change through serving notice (as per format enclosed with the Proposal Form) upon the Company, failing which, the Company shall be discharged of its liability to pay claims and the Company shall be free to rely upon the non-disclosure as grounds for refusing to pay a claim or for diminishing a claim which is otherwise payable.

*Note : A material fact is the information that is likely to influence the judgment of a takaful company when determining whether to provide a business with cover and the amount of contribution to be charged. It is the duty of the customer to disclose material facts that could be relevant to the coverage provided by the takaful company.

Signature

Clear

Group Health Proposal Form

Client Details

Basic Information

Past Experience

Required Benefits

Takaful Pakistan Limited