NIVESQOO · Health Insurance Form

1. Proposer Details — Premium Payer

Full Name *Required

Date of Birth *Required

Gender *Required

Mobile *Valid 10-digit required

Email *Valid email required

Education

Occupation *Required

Gross Yearly Income *Required

Company / Employer

Designation

Company Address

Industry

2. Insured Members

Add all family members to be covered. The proposer can also be listed as an insured member.

3. Existing Policy & Nominee

Existing Health Policy?

Nominee Name *Required

Nominee Date of Birth

Nominee Relation *Required

Nominee MobileValid 10-digit required

Nominee Email

Nominee KYC Documents

Nominee Aadhaar — Front *

ID

JPG, PNG, PDF · Max 5MB

Nominee Aadhaar front required

Nominee Aadhaar — Back *

ID

JPG, PNG, PDF · Max 5MB

Nominee Aadhaar back required

Nominee PAN Card *

PAN

JPG, PNG, PDF · Max 5MB

Nominee PAN required

4. Proposer KYC Documents

Upload clear, legible copies. All documents are embedded in the PDF for your advisor.

Passport Size Photo *

PHOTO

JPG, PNG · Max 5MB

Photo required

Aadhaar Card — Front *

ID

JPG, PNG, PDF · Max 5MB

Aadhaar front required

Aadhaar Card — Back *

ID

JPG, PNG, PDF · Max 5MB

Aadhaar back required

PAN Card *

PAN

JPG, PNG, PDF · Max 5MB

PAN required

Income Proof (Optional — Salary slip, ITR, Form 16)

DOC

PDF or image · Max 10MB

5. Declaration & Informed Consent

IRDAI Regulations 2024 IT Act 2000 (Amended) Aadhaar Act 2016 · Sec 29 DPDP Act 2023

Purpose of Data Collection

Your personal details, health information, and KYC documents (Aadhaar, PAN) are being collected solely for the purpose of evaluating and recommending a suitable health insurance product as per IRDAI (Insurance Brokers) Regulations 2018 and IRDAI (Protection of Policyholders' Interests) Regulations 2017.

Sensitive Personal Data — DPDP Act 2023

Health records, biometric identifiers, and financial details constitute Sensitive Personal Data under the Digital Personal Data Protection Act, 2023. NIVESQOO collects this data under your free, specific, informed, and unambiguous consent. This data will not be sold, shared with third parties, or used for any purpose other than insurance advisory.

Aadhaar & PAN — Usage Restrictions

Aadhaar details are collected in compliance with the Aadhaar Act, 2016 (Section 29) and are used strictly for identity verification for insurance KYC as mandated by IRDAI. Aadhaar and PAN documents will be used for this proposal only, will not be stored beyond the advisory engagement, and will not be shared with any entity other than the licensed insurer for policy issuance.

Data Retention & Right to Withdraw

As a Data Principal under the DPDP Act 2023, you have the right to access, correct, and erase your data at any time. You may withdraw this consent by writing to hello@nivesqoo.com. Upon withdrawal, your data will be deleted within 30 days unless retention is required by law (e.g. IRDAI record-keeping norms of 5 years post-policy).

I, the undersigned, hereby confirm that all information provided in this form is true, complete, and accurate to the best of my knowledge. I provide my free, specific, informed, and unambiguous consent under the Digital Personal Data Protection Act, 2023 and the Information Technology Act, 2000 (as amended) for NIVESQOO and the assigned IRDAI-licensed advisor to collect, use, and temporarily process my personal data — including Aadhaar, PAN, and health records — exclusively for the purpose of insurance advisory and policy issuance. I understand this form does not constitute a binding insurance contract.

Health Insurance Proposal

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