Optima RESTORE >> ApolloMunich Proposal Form HEALTH INSURANCE Proposal No: Every Information sought from applicant inthis application, more specifically against the medical and lifestyle question, is material and important for Apola Munich to underwrite the risk coverage of all proposed insured. Applicat i therefore advised to read all questions very carefully. Incase applicant has any doubt or requires any clarity on any part of this aplication form o the questions or ther answers, aplicant is advised to calla our tll ree number 1800 102 0333. Pease not, the premium value an the decision whether ornot tissue the Insurance Policy solely is based on information tat applicant provides inthis application. Thus applicant is advised to provide al information and answer all questions inthis application truthful, completly and correctly. At any ime, if any information given in this application is found tobe False! Incomplete/incarrect/patalycorect, Apollo Munch reserves the discretionary right to refuse the caver or cancel the policy, iit is issued. In event of cancelation af the Policy, no claim willbe payable. tis nat obligatay for us to accep any risk or issue policy to anyone, Regulations mandate that the coverage can incep only ater we have received the fll amount of premium and have explicitly accepted the risk 1, PROPOSER DETAILS Propose: (Mr/rs/Ms) Ms ‘yt Tryetw ‘Address: ‘aly Landmark City/Town: | New Deli District North Delhi State: | DELAT Telephone Mobile: | 989056156 Pin Code 10007 Email: [ high@ih.co Nationality Indian Marital Status: Single Annal Income iorreottpe = PANE] Passe CJ Drvngiense LJ voterscard L] otter [J Deas IDPret Ho 2. PLAN DETAILS Plan india Policy Period = From To ‘3. PROPOSED INSURED(S) DETAILS Details of Person Proposed to be Insured ame ofthe Insured Person | Height | Weight | Relationship to | Gonder | Date of Birth | Mobile No | Aadhar Ho | Sum Insured {inems)|(imems)| _ Poliyholder ‘mht Tyryetw eso fe [sett Female fosrioriges—_faasr0s61s6 fioooo00 4, NOMINEE DETAILS Inthe event ofthe death ofan insured Person any payment due under the Policy shall become payable to the nominee in accordance with the Policy terms and conditions. The nominee must be an inmediate relative ofthe Prapaser. Nominee fr any ofthe persons proposed tobe insured shall e the Proposer. Nominee Name Relationship ‘Address of the Nominee bilgut Daughter iat, North Deli, New Dei, DELHI Inia, 10007 5. EXISTING/PREVIOUS INSURANCE DETAILS {the proposer or any of the persons proposed already insured under or proposed fora Health Insurance Policy for Inpatient Hospitalization with Apolo Munich Health Insurance Company Limited or any other insurance company? C1 Yes C1 No Note: Due to recent regulatory changes on portabity norms, portability benefits cannot be provided for polices bought online due to procedural formalities. In case you wish to aval portability benefits pease apply through our local office.Optima RESTORE >> ApolloMunich Proposal Form HEALTH INSURANCE 6, MEDICAL INFORMATION Have you or any ofthe person propased tobe insured ever suffered from/ are currently suffering | Wasured | sured | Tasured | Insured | sured | tnsured from any ofthe following: fersn | Person | Peron | fersan | Person | Person iL [Have you ever been diagnosed with Diabetes, Heart disease, Stroke or paralysis, Cancer | No Any organ failure or transplant, HIV (Human Immune deficiency vrs), HPV(Human Papilloma Virus, EBV (Epstein Barr Virus), Hep BV (Hepatitis B Virus) or Hep CV (Hepatitis C Virus) ii [Have you undergone any surgery OR hospitalization for more than 10 days in the past OR | No Are you awaiting any treatment or surgery that you have been advised Ti [Have you been under any regular follow up for any disease or complaint OR been under | No any medication regulary for mare than 2 weeks or noticed any growth or swelling inthe body? iu. [Have you experienced regular pain in any part of body OR restriction of any movement OR | — No dticulty in swallowing or breathing OR any ifculty in doing your activities of dally ving? jv. |Didyou ever have fits, persistent headache or persistent eough OR blood in stool or any | Wo bleeding from anyother orifice / body opening for more than 5 days? Wi hi. i. ie i {Section B Does any person proposed to be ‘Aleaho! ‘Smoke Pan Masala Others insured smoke or consume gutkha/ pan masala | (3Oml pegs of Hard Liquor! | (No.of cigarettes per day) | (No. of pouches) jor alohol If yes, please indicate the name and} Bottles of Boer/ Glass ofWines) quantity per week: Insured -1 0 0 0 0 Insured -2 Insured 3 Insured 4 Insured 5 Insured 6 [Does your or ny ofthe person proposed tobe insureds occupation armature ot | tasured | insured | insured | Insured | insured | insured nb involve working in mings explosive units, marin, electical, otal, oi/as or | parson t | Person 2 | Person'3 | Person 4 | Person’ | Person 6 (chemical industry. armed fores; handling of heavy machinery or hazardous materials driving of heavy motor vehicles, working at heights or significant {manual labor? 7. GENERAL EXCLUSIONS The following isan outline ofthe main exclusions under the plc. For more details onthe exclusions and the wating periods please refer to the policy wordings before purchasing this policy. Waiting Periods - 30 days wating period inthe fist year andi not applicable in subsequent renewal 2 years wating prod forthe sped inesses/ surgeries. 3 years waiting perio for Pre-existing conditions. War or any act of warrit,strike: Any Insured Person committing or attempting to cammita breach of aw with criminal intent. or intentional ef inury or attempted suicide while sane or insane, Any Insured Person's participation or involvement in naval, military or airforce operation, racing, diving, vation, scuba diving, Daactuting, hanging, rock o mountain climbing, Abuse or the consequences ofthe abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and aleohol, including smoking cessation programs andthe treatment of rican addiction or anyother substance abuse treatment or services, o supplies. Treatment of Obesity and any weight control program. Plastic surgery or ensmetic surgery unless necessary as apart of medically necessary treatment cette by the attending Medical Practitioner for reconstruction following an Accident, Cancer or Burs. Congenital external diseases, defects or anomalies. tem cll therapy o surgery, or fonth hormone therapy. Venerea disease, sexually transmitted disease or illes; AIDS (Acquired Immune Deficiency Syndrame) and/or infection with HIV (Huan Immunodeficiency Virus) including but no limited to conditions related to or arising out of HIV/AIDS such as ARG (AIDS Refatd Complex), Lymphomas in brain Koposs sarcoma, tuberculosis Pregnancy including voluntary termination), miscarriage (except as result ofan Accident or Iless), maternity or ith incuding caesarean section) excep inthe case of ectopic pregnancy in elation to in- patient only. Ay specific time bound or ittime exclusions) applied by Us and specified in the Schedule and accepted bythe insured, The costs of any procedure or treatment by any person or institution that We ave tld You (in writing) is otto be used atOptima RESTORE >> ApolloMunich Proposal Form, HEALTH INSURANCE te of renewal ara any specific tine during the policy period 8, DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED [Ws Wehereby declare on my behalf and on behalf of all persons proposed tobe insured that the above statements, answers and/or particulars gvenby me are true ‘and complet in all respects t the best of my knowledge and that I/We am/are authorized ta propose an behalf ofthese ather persons. «| understand that the Information provided by me wll frm the basis of insurance pai, is subject to the Board approved undereriting policy of the Insurance Company and thatthe policy will came into farce only after fll receipt ofthe premium chargeable.» We further declare that We will notty in writing any change occuring nthe occupation or general healt ofthe ie to be insured proposer ater the proposal has ben submitted but before communication ofthe risk acceptance by the company. + I/We Aeclare and consent tothe company seeking medial information from any hospital who at anytime has attended onthe lf tobe isured/ proposer or trom any past tor present emplayer concerning anything which affects the physical and mental health ofthe life ta be assured/prapaser and seeking information from any Insurance company to which an aplication for insurance onthe ie tobe assured propose has been made for the purpse of underwriting the proposal and/or claim settlement.» I/ We authorize the company to share information pertaining tory proposal incuding the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority | understand thatthe AMI may terminate the policy immediatly, on grounds of misrepresentation, raud, non-disclosure of atrial facts or non-coopeation by any Insured Person or anyone acting on policy holder's behalf or on behalf of an Insured Person upon 30 days’ notice by sending an endorsement to Insured Person's adress shown in the Schedule without refund of premium. | confirm tat Ihave read the brochure and understood alte terms and conditions, coverage’, and ‘aclusion related to: pre-existing diseases, waiting period and exclusion) and | accept them, Date SECTION 41 OF INSURANCE ACT 1938 AS AMENDED BY INSURANCE LAWS AMENDMENT ACT, 2015 (PROHIBITION OF REBATES): No person shall allow ar offer to allow, either directly or indirecty, s an inducement to any peson to takeout or renew or continue an insurance in respect of any king of risk relating to lives ar property in India any rebate of the whole or part ofthe commission payable or any rebate ofthe premium shown onthe policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate, except such rebate as maybe allowed in accordance withthe published prospectuses or tables of the insurers Any person making default in complying with the provision of ths section shall be liable for a penalty which may extend to 10 lak rupees For detailed terms and condi ns, please refer insurance policy document FOR OFFICE USE ONLY Apollo Munich Health Office Code Advisor Code & Name Branch Receipt Date: Channel Type Busines type (Urban/Rura/ Socal)Optima RESTORE >> ApolloMunich Proposal Form HEALTH INSURANCE ‘gl Mure Het sans Co, Ui. © Cntr Procesiag Cn, 2nd 231d Fr, LABS Cane Pt No, 44-45, Ugo iar, Phase argeon 12016, Haryana © Cop OF. str, SE 19, Seto, Green 1220, Haryana ® Re. OM Ala Hosptals Complex, 82-288/82/ I/DH/90, bie i, Myer S00033, Teagan * Ace Payments Bak Lite OAL yrateaget (Alene No, CAO40) of Apolo March eat Insurance Carpany Lined AM Tisnsurane ply is underwrite by AMHL CantraettInsurance betwen the lua basis.* Farmar 151 cn usEosOTez00gPLCOStI6O* UNAPOHLIET2SvOSINS is ni ats tar and onions, please read sales brochure neu fore cncaog asl * IROL eg.