GOOD HEALTH SCHEME

APPLICATION  TO  RENEW WITH  CHANGES
 (This form should be issued in case of renewal only)

Please fill in the form if you want to renew with changes in Good Health Scheme. If you want to have some changes in insurance policy certificate, please mention 'Yes' in Change required coloumn and give exact details. All the columns need to be filled, otherwise we will not be able to process your request.  

Please note that names found in the form only, will be considered for insurance coverage.   

Click here to view the plan options (for Personal Accident and Mediclaim Policy)

GOODHEALTH  POLICY APPLICATION FORM
Sl.
No.

Name in full
(Underline Surname)

 Gender
  M/F

Date of
Birth
dd/mm/yy

 Relationship
with
Card Member		 Good Health Plan Choice
 (Please circle your plan choice)
Change
required
 		Specify name of
illness/disease/disablement
suffered/suffering with
period from
Personal
Accident
insurance

Mediclaim insurance

 illness/diseases/
disablement		 Existing
From
1            Yes/No    
2            Yes/No    
3            Yes/No    
4            Yes/No    
5            Yes/No    
6            Yes/No    

Have you included any new person ?   YES / NO    If Yes, Circle Sl.No(s) of the New inclusion(s)  1 | 2 | 3 | 4 | 5 | 6 |

Please complete and sign the following :

DECLARATION

I declare that all the persons proposed for Good Health Insurance include my relatives and/or myself only and that they are not engaged in any high-risk occupation as mentioned in the Terms and Conditions.  I also declare that none of them suffer from any pre-existing condition which is not fully cured and that I have explicitly given information on such instances of pre-existing illness/disease/disablement separately, if applicable. All the information given in this form on behalf of my family members and/or myself is correct and true to the best of my knowledge and belief and shall be the basis on which insurance is  granted. I also
authorize Diners Club/Citibank to charge the Premia and the Transaction Fee as applicable to choice of Plans indicated above to
my Diners Club/Citibank Card Account  as per details given below: I have read and agree to the Terms and Conditions of this offer.

Name                                                                                                    Date of Birth                           (DD,MM,YY)
                                                                                                                                  
Diners Club/Citibank Card Number                                                       Expiry Date on the Card               (MM,YY)

Current Certificate Number                                                                   (in case of renewal)

Address                                                                                                 Tel (Off)                                     

                                                                                                              Tel (Res)                                   

                                                                           Pin                               Email :

Date                                                                                                                              

The New India Assurance Co.Ltd
 Divisional Office - 712500		                   Signature
(of the Card Member as it appears on the Card)		       Citibank
      The Citi never sleeps

Please note that  Insurance Cover will start from 1st day of  Scheme Month.  Your filled in application should reach Citibank Card Centre, 2 Club House Road, Anna Salai, Chennai-600 002  on or before 15th of previous month of the Scheme month.