Heartbeat Health Insurance Policy Proposal Form

Please fill up this form in CAPITAL LETTERS for yourself and each proposed insured person. 1. Proposer Details Name Permanent Address

City State Current Address

District Pin code

City State Address for Communication Phone No. STD Code e-mail ID PAN No. Permanent Current

District Pin code

Landline No.

Mobile No.

(Mandatory for premium above Rupees one lac)

Marital Status Nationality Educational Qualification Occupation Salaried

Single

Married

Divorced

Widow(er)

Separated

Lesser than matriculation Self employed Student

Matriculation Housewife

Graduate

Post-graduate Others

Professional Course

If salaried, specify designation If self employed, specify business/occupation Annual Gross Income (in Rs.) Bank Details:
Bank Name Branch City Account Number Account Type Savings Current

V2

HT_Proposal Form_8.25 X 11.75 HT_Proposal Form_8.25 X 11.75

Coverage Selection: Section I Coverage Selection: Section I

1. Plan details Policy Type 1. Plan details

Family to Floater, number of 2 persons be covered If Family Floater, number of If persons be covered Adultsto +2 Children 1 Adult + 1 Child If Family First, number of person to be covered If Family First, number of person to be covered Adults__________

2 2 Adults Adults + +2 1 Children Child 1 Adult + 1 Child 1Adult + 2 Children Adults__________ Children __________

2 Adults + 1 Child 2 Adults 2 Adults 1Adult + 2 Children Children __________ Please tick/fill the relevant Please tick/fill the relevant boxes.

Proposed policy term (2 year term available onlyFloater for individual 2. Proposed policy term (22. year policy term available only policy for individual and Family plans) and Family Floater plans) 2 year 1 year 2 year 1 year

3 7.5 Lacs Lacs Silver 1 Lac 3 Lacs 3 Lacs 5 Lacs

5 Lacs 10 Lacs Gold 2 Lacs 4 Lacs 4 Lacs 10 Lacs

7.5 Lacs 15 Lacs 10 Lacs 20 Lacs

15 Lacs 50 Lacs

20 Lacs

b. Family First:

b. Family First: Silver

Gold

1 Lac 2 Lacs ,QGLYLGXDO6XP,QVXUHG ,QGLYLGXDO6XP,QVXUHG )ORDWHU6XP,QVXUHG )ORDWHU6XP,QVXUHG 3 Lacs 4 Lacs

3 Lacs 5 Lacs 5 Lacs 15 Lacs

4 Lacs

5 Lacs

10 Lacs 15 Lacs Please tick the relevan Please tick the relevant boxes.

4. Details Persons Proposed to be Insured 4. Details of Persons Proposed to be of Insured Name Male Gender Female Male (cm) Female Height Self Son Height (cm) Weight (kg) Spouse Daughter Weight Date of (kg) Birth Son Daughter Daughter-in-law Date of Birth Daughter-in-law Father Mother Father

Name Gender

Proposed Insured

Relationship with Proposer Relationship with Proposer Self Spouse Father-in-law Nationality

Father-in-law Mother-in-law Grandfather Grandson Grandmother Grandson Others______ Granddaughter Mother-in-law Grandfather Grandmother Granddaughter Nationality Graduate Post-graduate Post-graduate Professional Course Others

Proposed Insured

Others__

Qualification Matric Educational Qualification Educational Non-matric Matric Non-matric Graduate Occupation Salaried Salaried Occupation Self employed

Professional C

Self employed House wife Student Student

Others House wife

If salaried, specify designation If salaried, specify designation If self employed, specify business/occupation If self employed, specify business/occupation

Name Gender Male

Name Gender Female Male (cm) Female Height Self Son Height (cm) Weight (kg) Spouse Daughter Weight Date of (kg) Birth Son Daughter Daughter-in-law Date of Birth Daughter-in-law Father Mother

Proposed Insured

Relationship with Proposer Relationship with Proposer Self Spouse Father-in-law Nationality

Proposed Insured

Father

Father-in-law Mother-in-law Grandfather Grandson Grandmother Grandson Others______ Granddaughter Mother-in-law Grandfather Grandmother Granddaughter Nationality Graduate Post-graduate Post-graduate Professional Course Others

Qualification Matric Educational Qualification Educational Non-matric Matric Non-matric Graduate Occupation Salaried Salaried Occupation Self employed

Professional C 6.

Self employed House wife Student Student

Others House wife

If salaried, specify designation If salaried, specify designation If self employed, specify business/occupation If self employed, specify business/occupation

V2

V2

Proposed Insured 8

In t the ins Others__ N

Proposed Insured 6 Proposed Insured

Proposed Insured

3. Sum Assured (in Rupees) 3. Sum Assured (in Rupees) a.Silver Individual/Family Silver a. Individual/Family Floater: Floater: 25 Lacs 2 Lacs 3 Lacs Lacs

Gold

Gold

Platinum

Platinum

Proposed Insured

Policy TypeFamily Floater Individual Individual

Family Family FirstFloater

Family First

50

Not

5. N

In o Ple Ins

me Male

Name Gender Female Male (cm) Female Height Self Son Height (cm) Weight (kg) Spouse Daughter Weight Date of (kg) Birth Son Daughter Daughter-in-law Date of Birth Daughter-in-law Father Mother Father Mother

nder

Relationship with Proposer ationship with Proposer Self Spouse

Father-in-law

Father-in-law Mother-in-law Grandfather Grandson Grandmother Grandson Others______ Granddaughter Mother-in-law Grandfather Grandmother Granddaughter Nationality Graduate Post-graduate Post-graduate Professional Course Others

Proposed Insured

Others______

onality es.

Qualification Matric cational Qualification Educational Non-matric Matric Non-matric Graduate Salaried Salaried Occupation Self employed

Professional Course

upation

Self employed House wife Student Student

Others House wife

If salaried, specify designation laried, specify designation

If self employed, specify business/occupation lf employed, specify business/occupation

me Male

Name Gender Female Male (cm) Female Height Self Son Height (cm) Weight (kg) Spouse Daughter Weight Date of (kg) Birth Son Daughter Daughter-in-law Date of Birth Daughter-in-law Father Mother Father Mother

nder

Relationship with Proposer ationship with Proposer Self Spouse s

Father-in-law

Father-in-law Mother-in-law Grandfather Grandson Grandmother Grandson Others______ Granddaughter Mother-in-law Grandfather Grandmother Granddaughter Nationality Graduate Post-graduate Post-graduate Professional Course Others

Proposed Insured

Others______

ionality

Qualification Matric ucational Qualification Educational Non-matric Matric Non-matric Graduate Salaried Salaried Occupation Self employed

Professional Course

upation es.

Self employed House wife Student Student

Others House wife

If self employed, specify business/occupation elf employed, specify business/occupation

Proposed Insured 6 Proposed Insured

If salaried, specify designation alaried, specify designation

me Male

Name Male (cm) Female Height Height (cm) Weight (kg) Weight Date of (kg) Birth Date of Birth

nder

Gender Female

Relationship with Proposer Self Spouse Son Daughter Daughter-in-law Father Mother ationship with Proposer Self Spouse Son Daughter Daughter-in-law Father Mother her Father-in-law Mother-in-law Grandfather Grandson Grandmother Grandson Others______ Granddaughter Others______ Father-in-law Mother-in-law Grandfather Grandmother Granddaughter __ Nationality ionality Professional Course

Qualification Matric Graduate Post-graduate ucational Qualification Educational Non-matric Matric Non-matric Graduate Post-graduate Professional Course e Salaried Self employed House wife Student Others upation Salaried Occupation Self employed Student Others House wife

If salaried, specify designation alaried, specify designation

If self employed, specify business/occupation elf employed, specify business/occupation

Note: is for individual age bands and 3 geographical zones. emium is for individual agePremium bands and 3 geographical zones. If you space please use extra sheets. you need more space please use need extra more sheets.

ination

5. Nomination

dical History

In order for us to service fully, please the to questions below accurately to the best of your knowledge. for us to service you fully, please answer the you questions below answer accurately the best of your knowledge. Please ensure that you are fully informed about the standard waiting periods and permanent apply to the Max Bupa Health nsure that you are fully informed about the standard waiting periods and permanent exclusions that apply to the exclusions Max Bupa that Health Insurance Policies. ce Policies.
2

Proposed Insured 8

the event of the death ofdue the under proposer payment due under the policy become payable the nominee vent of the death of In the proposer any payment theany policy shall become payable to theshall nominee proposed in to this form and proposed in this form and the receipt of the proceeds by such nominee would be sufficient discharge to the Company. Nominee for all other persons proposed to be eipt her of the proceeds by such nominee would be sufficient discharge to the Company. Nominee for all other persons proposed to be insured shall be the proposer himself/herself. The following section is to be filled by the proposer: shall be the proposer himself/herself. The following section is to be filled by the proposer: __ Nominee Name Relationship Address of Nominee ee Name Relationship Address of Nominee

6. Medical History

V2

V2

HT_Proposal Form_8.25 X 11.75 HT_Proposal Form_8.25 X 11.75

Questions

Proposed Proposed Proposed Insured Questions Insured 1 Insured 2 Name Yes Name Name

Proposed Proposed Insured Insured 3

Proposed Proposed Insured Insured 1 4

1) Within the last 2 years, have you consulted a doctor or a healthcare professional? 2) Within the last 7 years, have you been to a hospital for an operation and/or an investigation (e.g. scan, x-ray, biopsy or blood tests)? 3) Do you take tablets, medicines or drugs on a regular basis? 4) Within the last 3 months, have you experienced any health problems or medical conditions which you have not seen a doctor for?

Name Name Yes No Yes No Yes No Yes No No 1) Within the last 2 years, have you consulted a doctor or a healthcare professional? 2) Within the last 7 years, have you been to a hospital for an operation and/or an investigation (e.g. scan, x-ray, biopsy or blood tests)? 3) Do you take tablets, medicines or drugs on a regular basis? 4) Within the last 3 months, have you experienced any health problems or medical conditions which you have not seen a doctor for?

Name Name Yes Yes Yes No No Yes

Proposed Proposed Insured 5 2 Insured Name Name

Proposed Proposed Insured 6 3 Insured Name Name

Proposed Proposed Insured 7 4 Insured Name Name

Proposed Proposed Insured 8 5 Insured Name Name

Proposed Proposed Insured 9 6 Insured Name Name

Proposed Proposed Insured10 7 Insured Name Name

TheP Proposed Proposed Proposed Proposed Proposed Proposed Insured11 8 Insured Insured12 9 Insured 10 Insured the 11 I Insured Name Name Name Name N Add Name Name
No Yes Yes No No Yes No No Yes

No Yes Yes No

No Yes Yes No

No Yes Yes No

No Yes Yes No

No Yes Yes No

No Yes Yes No

Con No Y

trea conv cont diso diso

For to a Polic

* Sto Men gast

If an will o be b

Ther

Base Prop

Cov

1. C

By c

We may have questions for you or may askto you to undergo testsasssessment. to complete your full medical asssessment. Note: We may have additional Note: questions for you oradditional may ask you to undergo medical tests complete yourmedical full medical

7. Additional Information7. Additional Information If you have yes in response to any6, ofplease the questions in section 6, If please give full details here. If you If you have answered yes in response toanswered any of the questions in section give full details here. you need more space please use need more space please extra sheets. If you are unsure whether any details are relevant, please include them. extra sheets. If you are unsure whether any details are relevant, please include them. The relevant question number from section 6 Please specify as Please specify as accurately as possible The accurately as possible What treatment When did thedid When did the or the the symptoms the symptomsrelevant or the you receive and when symptoms start Name of condition. medicalstart condition. question symptoms medical (please include dates and/or when was Proposed when was Where applicable, number and/or Where applicable, ofthe treatment and treatment Insured the treatment please state the area please state thefrom area any medication completed? completed? of the body affected section 6 of the body affected prescribed)? (e.g. right leg, left eye). (e.g. right leg, left eye).

Name of Proposed Insured

What treatment did you receive and when Gen What was the outcome of What was the outcom (please include dates the treatment (e.g. ongoing,the treatment (e.g. ong 1. F of treatment and complete recovery, recu complete recovery, recurrent any medication or likely to recur)? or likely to recur)? prescribed)? Fam

Ad

Cit

Sta

2.

a. ID

b. A

V2

V2

The following are the permanent exclusions under the Policy. For further details on the exclusions, please refer to the terms and conditions of wing ed are the permanent exclusions under the Policy. For further details on the exclusions, please refer to the terms and conditions of the Policy. y. d 12

Addictive conditions and disorders; Ageing and puberty;Circumcision; Artificial life Conflict maintenance; Circumcision; Conflict and disaster; Congenital conditions; conditions and disorders; Ageing and puberty; Artificial life maintenance; and disaster; Congenital conditions; Convalescence and Rehabilitation; Cosmetic surgery; Dental/oral treatment; Drugs and dressings for Out-patient or take-home use; Experimental cence and Rehabilitation; Cosmetic surgery; Dental/oral treatment; Drugs and dressings for Out-patient or take-home use; Experimental No Eyesight; hydros, cure, wellness clinics HIV etc; and Hereditary conditions; HIV and AIDS; and Items of personal comfort and nt; Eyesight; Healthtreatment; hydros, nature cure,Health wellness clinicsnature etc; Hereditary conditions; AIDS; Items of personal comfort convenience; Non-allopathic treatment; Obesity; Out-patient Treatment; Psychiatric and Psychosomatic Conditions ; Reproductive medicine - Birth nce; Non-allopathic treatment; Obesity; Out-patient Treatment; Psychiatric and Psychosomatic Conditions ; Reproductive medicine - Birth control & Assisted reproduction; Self-inflicted injuries; Sexual problems and gender issues; Sexually transmitted diseases; Sleep disorders; Speech & Assisted reproduction; Self-inflicted injuries; Sexual problems and gender issues; Sexually transmitted diseases; Sleep disorders; Speech disorders; Treatment for developmental problems; Treatment received outside India; Unlawful Activity; Unrecognised physician or Hospital, Genetic ; Treatment for developmental problems; Treatment received outside India; Unlawful Activity; Unrecognised physician or Hospital, Genetic disorders; any other such permanent exclusions as may be specified in the Schedule ; any other such permanent exclusions as may be specified in the Schedule

Forabove all insured persons who 60of years of age as on the date of commencement of thebelow Policy, the conditions sured persons who are 60 years of age asare on above the date commencement of the Policy, the conditions listed will be subject listed below will be subject to a waiting period of 24 months and will be covered in the third Policy Year as long as the Insured Person has been insured continuously under the ng period of 24 months and will be covered in the third Policy Year as long as the Insured Person has been insured continuously under the Policy without any break: thout any break:

* Stones in the urinary system (example kidney, bladder) Stones instones)* billiary system (example gal stones)* Cataract * Benign prostatic hypertrophy * in the urinary system (example kidney, bladder) Stones in billiary system (example gal Cataract * Benign prostatic hypertrophy * Mennoraghia, fibromyoma, uterine prolapse including any condition requiring hysterectomy * Piles (Haemorrhoids) * Hernia (inguinal/umbilical and ghia, fibromyoma, uterine prolapse including any condition requiring hysterectomy * Piles (Haemorrhoids) * Hernia (inguinal/umbilical and gastric) * Degenerative disorders of knee/hip Chronic renal failure or end stage renal failure * related Retinopathy * Diabetes and related treatments Degenerative disorders of knee/hip * Chronic renal failure or end *stage renal failure * Retinopathy * Diabetes and treatments

If any Person 65 years age or over on the date of commencement the Policy, then Company Max BupaLimited Health Insurance Company Limited ured Person is 65 years ofInsured age or over onis the date ofof commencement of the Policy, then Max Bupaof Health Insurance will only pay 80% of the amount assessed forin payment or any reimbursement of any claim made by balance that Insured pay 80% of the amount assessed for payment or reimbursement respect of claim made in byrespect that Insured Person and the will Person and the balance will be borne by the Insured Person. by the Insured Person.

There could bethe certain declined norms risks asof per the underwriting norms of the Company. uld be certain declined risks as per underwriting the Company.

Based on our assessment of your some conditions may have periods or exclusions our assessment of your health, some conditions mayhealth, have additional waiting periods or additional exclusions waiting applicable to any/all of the applicable to any/all of the Proposed Insured. d Insured.

Coverage Selection: Section II e Selection: Section II

1. Cost Sharing option(Available for Silver options of Individual Sharing option(Available only for Silver SI options of only Individual andSI Family Floater Plans): and Family Floater Plans):

By choosing one of the cost sharing options below you can getin the corresponding discount in your ing one of the cost sharing options below you can get the corresponding discount your premium calculations for thispremium policy, calculations for this policy, 1 Lac annual aggregate deductible. 1 Lac annual aggregate a. deductible. b. 2 Lacs annual aggregate deductible. 2 Lacs annual aggregate deductible. c. 3 Lacs annual aggregate deductible. 3 Lacs annual aggregate deductible. Deductible optionPremium Discount percentage Premium Discount percentage Youmarking can choose only one option marking Yes You can choose only one option Yes 25% 33% 45%

ductible option

1 Lac annual aggregate deductible. ac annual aggregate deductible. 25%

2 Lacs annual aggregate deductible. acs annual aggregate deductible. 33%

3 Lacs annual aggregate deductible. acs annual aggregate deductible. 45%

General Selection: Section III Selection: Section III g, 1. Family Physicians Details ly t Physicians Details

Physicians Name Family Physicians Name Address

City State

District

District Pin code Pin code

cklist of Documents 2. Checklist of Documents Proof Passport a. ID PAN Card Passport Voter ID PANDriving Card License Voter ID Letter Driving License Public Letter from Recognised Public Authority from Recognised Authority Others PAN CardPassportVoter ID PAN Card Others
5 5

oof

Others

Proof
4

b. Age Proof Certificate School/College Leaving Certificate School/College Leaving Passport Driving License

Voter ID

Driving License Public Letter from Recognised Letter from Recognised Authority Others Public Authority

V2

V2

HT_Proposal Form_8.25 X 11.75 HT_Proposal Form_8.25 X 11.75

3. Existing Insurance Details 3. Existing Insurance Details 7. Isthe thepersons proposer or any of to be insured, insured proposed for a for health insurance policy fo Is the proposer or any of proposed tothe be persons insured, proposed already insured under oralready proposed for a under healthor insurance policy Ih in-patient with MaxCompany Bupa Health Insurance Company Limitedcompany? or any other insurance company? in-patient hospitalisation with Maxhospitalisation Bupa Health Insurance Limited or any other insurance pr fo If yes, indicate below the Policy/Application number(s) (Please mention application number in case of a pending proposal) If yes, please indicate below the please Policy/Application number(s) (Please mention the application number inthe case of a pending proposal) Pr by Since when have you been continuously insured (please provide the insurance history of atleast last 3 years f Since when have you been continuously insured (please provide the insurance history of atleast last 3 years for pr each proposed insured person if they have been continuously insured) each proposed insured person if they have been continuously insured) an Name Name Application Policy Application No. Policy No. No. No. Insured from (date) Insured from (date) To (date) Sum (if Insured To (date) Sum Insured Claim details any)

Claim details (if an

Da

Pla

8. In addition the information above, submit to Us proposal (as an annexure to this proposal form) In addition to the information givento above, please also given submit to Usplease (as an also annexure to this form) portability form and all portability form and Ih other documents as mentioned in the portability in order to avail of the portability benefit from policy your existing insurancefro p other documents as mentioned in the portability form in order to avail of form the portability benefit from your existing insurance

4. Renewal Payment Sign-up 4. Renewal Payment Sign-up Payment of renewal premium of yourcan health insurance policy can be made every year your existing ECS instru De Payment of renewal premium of your health insurance policy be made every year through continuing yourthrough existing continuing ECS instructions with Us. Under this option, your policy can be renewed promptly, but subject to you completing all additional requiremen with Us. Under this option, your policy can be renewed promptly, but subject to you completing all additional requirements of Ad information and be documentation as may be required by Max Bupa. information and documentation as may required by Max Bupa. Would you like to opt for the ECS renewal option at this stage? Would you like to opt for the ECS renewal option at this stage? Yes Yes No No

un un

Cit

you have chosen above please fill up attached the ECS Mandate form along with this form. If you have chosen Yes If above please fill up Yes the ECS Mandate form along with thisattached form.

Sig

5. Caution 5. Caution are obliged to make a full frank disclosure all facts material torelation the assumption of risk in person relation to you and You are obliged to make a You full and frank disclosure of all and facts material to theof assumption of risk in to you and every proposed to every person propo be insured that would influence our decision to issue a policy, or the terms on which it is issued. You must not misrepresent any informa be insured that would influence our decision to issue a policy, or the terms on which it is issued. You must not misrepresent any information to us. The obligation continues until the Policy is issued, and does not end with the submission of this proposal form. If, therefore, there us. The obligation continues until the Policy is issued, and does not end with the submission of this proposal form. If, therefore, there is any change in the information given herein or new information comes to light before the Policy is issued, then you must inform us of the s change in the information given herein or new information comes to light before the Policy is issued, then you must inform us of the same in writing without delay. If there is insufficient space to provide additional information, whether as requested or otherwise, then please att writing without delay. If there is insufficient space to provide additional information, whether as requested or otherwise, then please attach an extra sheet duly signed. If the disclosure obligations are breached then this may render any policy issued void. extra sheet duly signed. If the disclosure obligations are breached then this may render any policy issued void.

Authorisation (Please carefully and put a check mark against each before signing) 6. Authorisation (Please 6. read carefully and put a read check mark against each before signing) I consent to and authorise Max Bupa Health Insurance and/or any of its authorised representatives to seek m I consent to and authorise Max Bupa Health Insurance Company Limited and/orCompany any of itsLimited authorised representatives to seek medical information from any hospital/medical that I to or be any personhas proposed to be insured has attended or may attend in the information from any hospital/medical practitioner that I or anypractitioner person proposed insured attended or may attend in the future any disease or illness or injury. concerning any disease orconcerning illness or injury. I further consent to Health and authorise Max Bupa Health Insurance Company Limited to use and disclose any personal I further consent to and authorise Max Bupa Insurance Company Limited to use and disclose any personal information collected or information colle available with Max Bupa Health Insurance Company Limited in this proposal form obtained) to its under available with Max Bupa Health Insurance Company Limited (whether contained in this(whether proposalcontained form or otherwise obtained) to or its otherwise underwriting personnel, claims investigation companies/agencies/service provider and insurance/reinsurance as is necessary and required personnel, claims investigation companies/agencies/service provider and insurance/reinsurance companies as is necessarycompanies and required for the purpose of processing this proposal form and providing subsequent services in relation to the policyunder and processing of claims under the p purpose of processing this proposal form and providing subsequent services in relation to the policy and processing of claims the policy. I also consent to provide Max Bupa Health Insurance Company andrepresentatives /or any of its authorized representatives I also consent to provide Max Bupa Health Insurance Company Limited, and /or any of itsLimited, authorized any information and/or any information document with regard to the source ofthe my Proposed income and age of Proposed Insured, as Bupa may be sought by Max Bupa Health Ins document with regard to the source of my income and age of Insured, asthe may be sought by Max Health Insurance Company Limited. Company Limited.

Authorization for electronic policy fulfillment and service communications Authorization for electronic policy fulfillment and service communications * Ipolicy hereby consent that the documents may sent to me by email at _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(Please * I hereby consent that the documents may be policy sent to me by email at be _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (Please provide us your e-mail id) provide us your e-m Pro I hereby consent to Health and authorize Max Bupa Health Insurance Company Limited( Company) to make * I hereby consent to and * authorize Max Bupa Insurance Company Limited( Company) to make welcome calls, service callswelcome or any calls, service calls or an We other communication (electronic withor respect topolicy the proposed or existing policy ofto the Company from time to time. other communication (electronic or otherwise) with respector tootherwise) the proposed existing of the Company from time time. am Ne wh ter Dated Dated Signature of the ProposerSignature of the Proposer acc Place Place Name of Proposer Name of Proposer
6

Sig

V2

V2

7. Declaration laration I hereby on my behalf on behalf of each to of the persons proposed to be insured that the above information and the statements y declare on my behalf anddeclare on behalf of each of and the persons proposed be insured that the above information and the statements provided in this proposal form are true, complete and correct in all respects and that there is no information which is relevant to this application d in this proposal form are true, complete and correct in all respects and that there is no information which is relevant to this application for insurance that has not been disclosed to Max Bupa Health Insurance Company Limited. I further declare that I am related to each of the urance that has not been disclosed to Max Bupa Health Insurance Company Limited. I further declare that I am related to each of the Proposed Insured in the manner as stated by me herein and I have insurable interest in each of them. I also hereby declare that the money used ed Insured in the manner as stated by me herein and I have insurable interest in each of them. I also hereby declare that the money used by me to pay premium under this proposal has not been derived from any criminal or illegal activity or any unaccounted source. I agree that this to pay premium under this proposal has not been derived from any criminal or illegal activity or any unaccounted source. I agree that this proposal and any other information provided and the declaration shall be the basis of the contract between me and all persons to be insured al and any other information provided and the declaration shall be the basis of the contract between me and all persons to be insured and Max Bupa Health Insurance Company Limited. ax Bupa Health Insurance Company Limited.

Dated: Place

Signature of the ProposerSignature of the Proposer Name of Proposer Name of Proposer

8. Vernacular Declaration nacular Declaration I hereby declare that I have fully theform contents of other the proposal formincidental and all other documents incidental to availing the health insurance y declare that I have fully explained the contents of explained the proposal and all documents to availing the health insurance from Max Bupa Health Insurance Company Limited to the Proposer in the language understood by him/her. The same have been fully Max Bupa Health Insurance Company Limited to the Proposer in the language understood by him/her. The same have been fully understood by him/her the replies been recorded as per by the information by the Proposer. Replies have been read out to, fully tood by him/her and the replies have been and recorded as perhave the information provided the Proposer. provided Replies have been read out to, fully understood and confirmed by the Proposer. tood and confirmed by the Proposer. Declarants Name: Address: City Pin Code Pin Code

ns ants Name: of s:

ure of declarant:

Signature of declarant:

Signature of applicant in vernacular: Signature of applicant in vernacular:

to to ny in an

cal re

or ng he y. or ce

d) al Form No.

Acknowledgment Acknowledgment
Proposal Form No. Date Date

We acknowledge thanks theand receipt of your proposal and amount by Cash/Cheque/Demand Draft/ Others ________________________ of nowledge with thanks the receipt ofwith your proposal amount by Cash/Cheque/Demand Draft/ Others ________________________ of amount of Rs. ___________________________ dated ___________________________ drawn on ____________________________ . t of Rs. ___________________________ dated ___________________________ drawn on ____________________________ . submission to usfor of insurance a completed proposal for insurance nor any payment for us any policy sought obliges us to agree to issue a policy, the submission toNeither us of a the completed proposal nor any payment for any policy sought obliges to agree to issue a policy, which decision is and always shall bediscretion. in out soleIfand discretion. If insurance, we accept it a proposal for insurance, it shall be subject to the policy decision is and always shall be in out sole and absolute we absolute accept a proposal for shall be subject to the policy and conditions and we shall have no liability whatsoever premium isand notin received us in full and If inwe time is not realized. If we do not nd conditions and terms we shall have no liability whatsoever if premium is not receivedif by us in full time orby is not realized. door not accept the proposal, we will inform you and refund the from payment, if any, received from you without interest. the proposal, we will inform you and refund the payment, if any, received you without interest.

Signature of the receiver and office seal ure of the receiver and office seal

V2

V2

For Office Use Only

Premium Payment Details: Amount Bank Name/Branch Max Bupa Branch Location Business Sourced By: Advisor/DST/Corporate Agency/Other Channels Name Proposal Received On: Date Processed By Customer ID Date Approved By Date Code No. Code No. Code No. Cash Cheque/DD No. Date Credit Card

Insurance Advisors Report

1. Name of the Proposer 2. Are you related to the Proposer? 3. If yes, nature of relationship? 4. Is this a proposal form for yourself? 5. Since when do you know the Proposer? Yes No Years Yes No Yes No Yes No Months Yes No

6. Are you satisfied with the identity of the Proposer?

7. Does the Proposer have any physical deformity/defect or mental retardation?

8. Have you explained the exclusions of the policy and has the Proposer personally completed the health declaration? 9. What is the Proposers state of health at the time of making of this proposal form? 10. Do you recommend acceptance of this proposal form considering all the factors, including moral hazard? Yes

No

Date :

Signature of the Insurance Advisor

STATUTORY WARNING AS PER SECTION 41 OF THE INSURANCE ACT 1938 PROHIBITION OF REBATES Payment of rebates is expressly prohibited under Section 41 of the Insurance Act, 1938. 1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind or risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the Insurer. 2. Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend to five hundred rupees.

Max Bupa Health Insurance Company Limited Corporate Office: D-1, 2nd Floor, Salcon Ras Vilas, District Centre, Saket, New Delhi - 110017. Registered Office: Max House, 1, Dr. Jha Marg, Okhla, New Delhi - 110020 www.maxbupa.com Max and Max Logo are registered trademarks of Max India Limited. Bupa and the HEARTBEAT logo are the registered service marks of The British United Provident Association Limited. All these marks are being used under license by Max Bupa Health Insurance Company Limited. Insurance is the subject matter of solicitation

Neither the submission to us of a completed proposal for insurance nor any payment for any policy sought obliges us to agree to issue a policy, it shall be subject to the policy which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, terms and conditions and we shall have no liability whatsoever if premium is not received by us in full and in time, or is not realised. If we do not accept the proposal, we will inform you and refund payment, if any, received from you, without interest.

V2