1 1

1 1 1 1 1 1 1 1 1 1

1 1

1 1

1 1

1 1

Heartbeat Health Insurance Policy Proposal Form

Please fill up th is form in CAPITAL lETTERS for yourself and each proposed insured person.

1. Proposer Oetails

Name 1 1 1 1

Permanent Address

1 1

City

Dlstrkt

Pin code

State

Current Address

1 [ [

City [L____[------'-____J_____L_____J_____'_______'___-'----L____[------'-____J_____L_____J_____'_____--'----'----L__j____J_____J[ Oi strict

State [,----,------,-____J_____L_____J_____,_______,___-,----,---,------,-____J_---,-____J_____,_____--,----,----,---,____J_----'----'-___'_--'---'----'----J..........JI Pi n code L...-..J..__'_---,----,--...J......_J

Address for Communication D ermanent

DCurren

Phone No. STD Code 1 1 1 1 1 1

E-maillO 1 [ 1 1 1 1 1 1 1 1

PAN No. 1 [ 1 1 1 [ 1 1 1

land line No. c_1 ----,I____J_I----'-_____'____jl,----,I____'____j

1 1

[ 1 1 1 1 1

1 (Mandatory for premium above Rupees one lac)

1 1

Mo bile No. l_1 ____J_____'_____--'------,----'----'------'--____J______'_____j

1 1

Marital Status

D Single

D Married

D Divorced

D Widow(er) D Separated

Nationality ,-----I -'-------'---___[L____[____J[._______j__1 __J_I _._[ -----'-------'------'-----_L_I ----,---I -----,--I -----,1-----,-----1 _.__[ --,---I ____._I ____._[ ~IL__. _L_I --,----,--I ---,-I __jl------,-----I _._I ----,---I -----,--1-----,1---,--1 -,--I _j__jl

Educational Qualification

D lesser than matriculation D Matriculation D Graduate D Post-Graduate D Professional Course

Occupation D Salaried D Self employed

DStudent

D Housewife

D Others

If salaried, specify designation 1 1 1 1 1 1 1 1

'----'------'--____J__L_____J_____'_____~-'----l____[------'--____J______'_______'____'_____--'------'----l____[____J_----'-_____'______'_--'----'------'----J..........J____J_-----'

1 1 1 1

If self employed, specify business/occupation Bank Details:

Bank Name

Branch

1 1

1 1 1 1 1 1 1 1 1 1

1 1

1 1

1 1

1 [

City

I 1

Account Number

~------'--____J__L_____J_____'_______'____'____~------'-____J__L_____J_____'_______'____'____l____[____J_____J__L__jL_--'----'------'----L__j____J_____J______'____jL_~

Account Type D Savings D Current

2. Polic Details

Policy Type 0 Individual D Family Floater

If Family Floater, number of persons to be covered 0 2 AdultH2Chiidren D 1 Adult+ 1 Child

o 2Ad U ItH 1 Child

o 1 Adult+2Children

D2Adults.

3. Sum Assured (In Rupees)

o 2lac

D 3lac

Gold

Platinum

Silver

o Slae D 7.SLa.c D 10La.c

o lSlac

D 20Lac D SOlllc

Please tick the relevant boxes. ~ A Max India Joint VlIIlture

'""""""

4. Details of Persons proposed to be insured

I I I I

I I II I I I I I I I I

I I

I I I I

Name

..

Height (em) I I I I Weight (kg) 1 I I 1

Date of Birth

Gender D Male

D Female

Relationship with proposer D Self

D Spouse

DSon

D Daughter

D Others I I I I I I I I I I I

D Non-rnatrlc D Matric

D Graduate

D Post-Graduate D Professional Course

.. Educational Qualification

..

: Occupation D Salaried

D Self employed

DStudent

DHousewife

D Others

If salaried, specify designation I I I I I

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

If self e mp I oyed, specify bu si ness/ occu patio n LI ---'------'-------'-------'-------'---___j_____j_____j____l_____L____L____L____L____L____L___j____j___L___L____j____j____j___!___j_______j

Name 1 I 1 I I 1 I I 1 I I 1 I I I

I [

Weight (kg) c_1 --'---_L_I ---,I

I [

Height (em) I I I I

Gender D Male D Female

Date of Birth

..

D Spouse

DSon

DDaughter

D Others I I I I I I t I I t I

Relationship with proposer

D Non-rnatrlc D Matric

D Graduate

D Post-Graduate D Professional Course

.. Educational; Qualification

: Occupation D Salaried

..

D Self employed

DStudent

DHousewife

D Others

~~laM~spec~~~gn~oo L[---'--I____'___I~[~I~~~~~~~~~~~~~~~~~~~~~~____'_______'___~ If self employed, specify business/occupation [

~~~~~~~~~~~~~~~~~~~~~~~~~

Name 1 I 1 I I 1 I I 1 I I 1 I I I

I [ I I [

Weight (kg) 1 I I 1

Date of Birth

[_j_] [Q] B 1M] [Y] [Y][Y][Yl

Height (em) I I I I

Gender D Male D Female

D Spouse

DSon

DDaughter

D Others I I I I I I I I I I I

Relationship with proposer

D Non-rnatrlc D Matric

D Graduate

D Post-Graduate D Professional Course

.. Educational Qualification

: Occupation D Salaried

..

D Self employed

DStudent

DHousewife

DOthers

~~laM~spec~d~gn~oo LI~I~I~I~I~~~~~I~I~~~~~~~~~~~~~~~~~___'__~

If self employed, speclfy business/occupation I 1 I

L__~L__L__~~~~~~~~~~~~~~~~~~~~~

Name 1 I I I I 1 II 1 I I

I I 1 I I

I I I I Weight (kg) 1

I I I

I I 1

Date of Birth

Gender D Male D Female

Height (ern)

..

{ Relationship with proposer

DSpouse

DSon

D Daughter

DOthers I I I I I I I I I I I I

D Non-metric D Matric

D Graduate D Post-Greduate D Professional Course

.. Educational Qualification

: Occupation D Salaried

..

D Self employed

D Student

D Housewife

DOthers

~~Iari~spec~d~gn~oo L_1~1~1~1~1~~~~~I~I~I~I~~~I~I~~~___j__~~~~~~~~

If self employed, specify business/occupation ,---I ~~~~~I~I~I~I~~~I~I~~____L~~------'--~~___'____'_____[_~~

Note: Premium is for individual age bands and 3 geographical zones.

5. Nomination

In the event of the death of the proposer any payment due under the policy shall bec.ome payable to the nominee 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 insured shall be the proposer himself/herself. Following section to be filled by the proposer.

Address of nominee

Nominee Name

Relationship

o

16. Medical History

In order for us to service you fully, please answer the questions below accurately to the best of your knowledge.

Please ensure that you are fully informed about the standard waiting periods and permanent exclusions that apply to the Max Bupa Health Insurance policies.

Questions Proposed Proposed Proposed Proposed
Insured Insured 1 Insured 2 Insured 3
Name Name Name Name
Yes No Yes No Yes No Yes No
1) Within the last 2 years have you consulted a doctor or healthcare D D D D D D D D
professional?
2) Within the last 7 years have you been to a hospital for an operation D D D D D D D D
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? D D D D D D D D
4) Within the last 3 months have you experienced any health
problems or medical conditions which you have not seen a doctor for? D D D D D D D D Note: In addition to the above, we may have additional questions for you or may ask you to undergo medical tests to complete your full medical esssessment,

7. Additional information

If you have answered yes to any of the questions in section 6, please give full details here. If you need more space please use extra sheets. If you are unsure whether any details are relevant, please include them.

Please specify as
The accurately as possible When did What treatment did
relevant the symptoms or you receive and when What was the outcome of the
Name of medical condition. symptoms start (please include dates treatment (eg ongoing,
question and/or when was
proposed number Where applicable, of treatment and any complete recovery, recurrent
insured treatment
from please state the area completed? medication or llkely to recu r)?
section 6 of the body affected prescribed?
(eg Right leg, left eye) Name

Application No.

To [Date)

Claim details (ifany)

The following are the permanent exclusions under the Policy, For further details 01"1 the exclusions, please refer Ito the terms and conditions of the policy.

Addictive conditions and disorders; Unrea:sonable Charges; Ageing and puberty; Artificial life mainternance; Reproductive medicine [Birth control and Assisted reproduction); Conflict and disaster; Congenital conditions; Conva.lescence and rehabi'litation; Cosmetic surgery; Dental/oral treatment; Drugs and dressing for outpatient or take-home use; Experimental treatment; Eyesigrnt; Health hydras, nature cure clinics etc.; HIV and AIDS; Hereditary condirtions; Obesity; Self-infli'cted injuries; Sexual problems and ge:nder issues; Sexually transmitted diseases: Sleep disorders; Speech disorders; Unrecognised physician or facility; Clrcamdslon: Non-allopathic treatment; Items, of personal comfort and convenience; Mental illness; Treatment for developmental problems; Treatment received outside Indlia; Outpatient treatment.

For all insured persons who are' above 60 years of age as 011 the date of commencement of the Policy; the conditions listed below will be subject to a waTlting 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:

* Stones in the urinary .system *' Stones in billiary system" Cataract ~ Benign prostatic hypertrophy * Mennoraghia, Fibromyoma, Uterine prolapse including any condition requiring Hysterectomy" Piles (Haemorrhoids)" Hernia (Inguinal/umbilical andl ga.stric)"' Degenerative disorders oflknee/h1:p'~ Chronic renal failure or end sta:ge renal failure" Retinopathy" Diabetes and related treatments,

If any lnsured Person ls 6S years of age or over on the date of corn men cement of the Policy, then Max Bupa Health Insurance Company Limited will only pay 80% of the amount assessed for payment or reimbursement ln respect of any claim made by that Insured Person and the balance will be borne by the Insured Person.

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

Ba!seci on our assessment of your health, some conditions may have additional waiting periods or exclusions applicable to any/aU of the proposed insured.

Please fill in thefoUowing:

Fa,mllly Physician's name

Address

City

District

Pin code LI --,"_I....-"__'__.J..,_.J

State

8. Checklist of documents

a.1DProof

o Passport 0 PAN Card

OVoterlD

o Driving Licence 0 Letter from Recognised Public Authority 0 Others

b.Age Proof 0 School/CoUeg'e leaving Certificate

o Passport

o PAN Card

o Voter 10

o Driving Licence 0 LetteT from Recognised Public Authority 0 Others

9, Existlng_lnsurance DI?!<lils _

Is the proposer or any of the persons proposed to be insured, already iinsured under or proposed for a health insurance policy for inpatient hospitalisation with MilX' Bupa Health Insurance Company limited or <lny other tnsurance company?

If yes, please indicate below the Policy/Application nurnberts) (Please mention applleatlon number in ease of pending proposal)

Since when have you been contlnuously insured t [Q] [Q] 1M ~ [YJ IYl [YJ [YJ

Policy No.

Sum Insured

10, Automatic Renewal Sign-up

Your healthinsurance policy can be automatically renewed every year. Would you like to opt for this facility?

o Yes

ONo

Signature of the Proposer

11. Caution

You are obliged to make a full and frank disclosure of all facts material to the assumption of risk in relation to you and every person proposed to be insured that would influence our decision to issue a. policy, or the terms on which it is issued, and you must not misrepresent any information to us. This 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 same in wri.ting 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.

12. Authorisation

I consent to and authorise Max Bupa Health Insurance Company Ltd. and/or any of its authorised representatives to seek medical informati.on from any hospital/medical practitloner that I or any person proposed to be insured has attended or may attend in future concerning any disease or illness or Injury.

D I further authorise Max Bupa Health Insurance Company Limited to use and disclose any personal information collected or available with Max Bupa Health Insurance Company Limited (whether contained in this application or otherwise obtained) to underwriting companies, claims investigation companies/agencies and Insurance/reinsurance companies for the purpose of processing of this Application and providing subseq uent services.

D I consent to receive information from the Company through electronic and telecommunication means from time to time.

13. Declaration

I hereby declare on my behalf and on behalf of each ofthe persons proposed to be insured that the 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 for insurance that has not been disclosed to Max Bupa Health Insurance Company Ltd. I agree that this proposal. and any other information provided and the declaration shall form the basis of the contract between me and all persons to be insured and Max Bupa Health Insurance Company Limited.

Dated: [QJ [Q] 10 IS1l IYlIYlIYl [YJ

Signature of the Proposer

Place

----------------------------

Name of Proposer

14. Vernacular Declaration

I hereby declare that I have fully explained the contents of the application form and all other documents incidental 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 understood by him/her and the replies have been recorded as per the information provided by the proposer and the replies have been read out to, fully understood and confirmed by the proposer.

Declarant's Name:

Address:

City

Signature of declarant: Signature of applicant in vernacular:

Acknowledgment

Application No. I Date IDJ IQ] 1M 1M [1J ['{] [Y] [Y]

We acknowledge with thanks the receipt of your application and amount by Cash/Cheque/Demand Draft/others of amount of

R.s dated drawn on ,

51g natu re of therecelV<!T and office sea I

n

n

For Office Use Only

Premium Payment Details: D Cash D Cheque/DO No.

Am ou nt ,---I ----,-------,-------,-------,-------,---1 ----' Date [[21 [;2] IMIIMl [YJ [YJ [YJ [YJ

D Credit Card

Bank Name/Branch

Max Bupa Branch Location

CadeNa.

Business Sourced By: Advisor/DST/Corporate Agency/Other Channels

Code No.

Name

Code No.

Proposal Received On:

Processed By

_______ Date [Q] [Q] IMIIMI [YJ [YJ [YJ [YJ Approved By

______ Date [Q] [Q] IMlIMl [YJ [YJ [YJ [YJ

1 1

Customer 10

Insurance advisor's report

r

r J

1. Name of the Proposer

2., Are you related to. the Propaser?

DYes DNa

3. If yes, nature of relationship?

4. Is this an applicatian far yourself?

DYes

DNo

5. Since when do you know the Proposer?

[I] Years

IT] Months

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

DYes 0 No

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

DYes

DNa

8. Have you explained the exclusians afthe policy and has the Proposer personally completed the health declaration?

D Yes DNa

9. What is the Proposer's state of health at the time of making of this a pplkation?

10. Do you recommend acceptance of this application considering all the factors,including moral hazard?

DYes

DNo

Date: IG][] D D 0CI1GJGJ

Signature of the insurance advisor

STATUTOfIYWAflNlNG AS PER SEmON 41 OF THE INSURANCE ACT 1938

PROHIBITION OF REBATES

Payment of rebates is el<pressly prob ibited under Section 41 of the Ins u renee Act, 1938.

1. No person shall allow or offer to allow either directly or Indirectly as an Inducement to any person to takeout or renew or continue an Insurance In respect of any kind or risk relating to lives or property in India a ny rebate of the whole or part of the commissi on payable or a ny rebate of the prem ium shown on th e pol icy nor shall any person ta king out or conti n u ing a policy accept anyrebate except such rebate as maybe allowed Tn 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 , 2n d Floor, Sa Icon Ras Vi la s, Distri ct Ce ntre, Saket, New Delh i - 11 0017.

Registered Office: Max House, 1, Dr. Jha Marg, Dkhla, New Delhi - 1 , 0020 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.

Ins ura nee Is a su b ject matter of soli citation

Neither the submission to us of a completed proposatfortnsurance nor any payment for any policy sought obliges us to agree to issue a policy. which decision is and always shall beln our sole and ebsolute discretion. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions and we shall have 'no liability whatsoever if premium is not received by us in full and in ti me, or is not reatlsed.

If we do not accept the proposal, we wi II inform you a nd refund payment. if any, received from yo u, without interest.