ENROLMENT FORM Enrolment Form No.

1. DETAILS OF ACCOUNT HOLDER

Name: (Mr./Ms./Mrs.)
First Name Middle Name Last Name

Address:
(We will send your Certificate of
Insurance here) City / Town
District State
Pin Code Email
Landline: (with STD code) Mobile

2. PLEASE SELECT YOUR PLAN

Type: Individual  Floater Plan  2A  2A+2C  2A+4C

(A = Adult, C= Child)

Individual Plan (You can cover yourself, your spouse, your children. Coverage will be on individual basis.
Family Plan (You can cover yourself, your spouse and upto 5 children in a single policy. Coverage will be on family floater basis)
Note: You cannot cover parents or parent in laws under these plans
Name Relationship to Gender Date of Birth (DD/MM/YYYY) Sum Insured *
Account holder
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
* Family plan will have same sum insured for all members. The premium for a family floater will be charged as per age of the eldest member.

Parents Plan (You can cover either your parents or your parents in law under this plan.)
Type: Individual  Family Floater Plan (2 adult) 

Name Relationship to Gender Date of Birth (DD/MM/YYYY) Sum Insured *

Account holder
 M  F D D M M Y Y Y Y
 M  F D D M M Y Y Y Y
* Family plan will have same Sum Insured for all members. The premium for a family floater will be charged as per age of the eldest member.
Nominee Details

Name Relationship Address of Nominee

Pl Note
Key Exclusions to note in your policy (This is only a brief summary of the exclusions in your policy, for details please refer to detailed policy terms and conditions)
All treatments within the first 30 days of cover except any accidental injury, 1 year waiting period for specified illness/ conditions, Pre-existing waiting period for
36 months for any disease ,illness or condition that existed prior to taking this policy. Treatment of obesity or any weight control program, psychiatric, mental
disorders, Parkinson and Alzheimer’s disease, congenital internal or external diseases, genetic disorders, sexually transmitted disease, “AIDS” (Acquired Immune
Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus), sterility / infertility treatment of any type, laser treatment for correction of eye
due to refractive error, aesthetic or change-of-life treatments, plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment for
reconstruction following an Accident, Cancer or Burns, experimental, investigational or unproven treatment.
3. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS TO BE INSURED
I confirm that I and other members proposed to be insured under this policy are in good health and have not suffered in last 5 years from any major disease/
disorder/ ailment or deformity (other than infrequent common cold, fever, loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetes
without any complication or hypertension without any complication)
And
I/We are neither awaiting any treatment medical or surgical nor attending any follow up for any disease / condition / ailment/ injury / addiction not specified in

1
 ENROLMENT FORM
this declaration.

Yes, I confirm  No, I can’t confirm 

I hereby declare and warrant on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects
and that there is no other information which is relevant for insurance that has not been disclosed to Apollo Munich Health Insurance Co.Ltd. I agree that this
declaration shall be the basis of the decision by Apollo Munich Health Insurance Company Ltd to cover or not cover us under insurance.
I agree that any refund due on the premium payment will be directly credited to my Bank Account as provided in the enrollment form.
4. DEBIT AUTHORISATION FOR CURRENT & FUTURE RENEWAL PREMIUMS
I hereby authorize Indian Overseas Bank to debit my account number
with the bank for Rs. towards first premium for availing the said
Apollo Munich Health insurance cover.

 I hereby request and authorize the Bank to debit my account number

on the yearly due dates with the applicable renewal premium.

DISCLAIMER: Apollo Munich Health Insurance Company Ltd. shall not be responsible/liable to anybody, in any manner, whatsoever for non credit/ delayed credit
of any payment due in relation to insurance policy into above bank account of Proposer/Policy holder and any other consequential loss directly/indirectly, for
whatsoever reasons thereof including but not limited to incomplete/incorrect information by Proposer/Policy Holder.

Signature of Account holder: Date: D D M M Y Y Y Y Place:

5. VERNACULAR DECLARATION (to be filled only if the proposer has signed in vernacular)
I have explained the content of this form and it’s particulars.
The account holder has understood and confirmed the same.

Signature of Account holder: Signature of the witness:

Date: D D M M Y Y Y Y Name of the witness:

Place: Relation to Account holder:

6. ACKNOWLEDGEMENT FROM CUSTOMER:

I hereby acknowledge the receipt of the Certificate of Insurance and the E-Card for the listed members as per the proposal submitted by me for availing the health
insurance cover from Apollo Insurance Company Limited.

Signature of Account holder: Date: D D M M Y Y Y Y Place:

SECTION 41 OF INSURANCE ACT 1938 (PROHIBITION OF REBATES):

No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or continue an insurance in respect of any kind of
risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of premium shown on the policy nor shall any
person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the
insurers.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Rs. 500.

To be filled by the bank

Branch Name: Branch Code:
India Overseas Bank A/c Number: A/c Type
Staff number of branch staff Staff number of MO/IO

Toll Free: 1800 3000 1501 • E-mail: iobcare@apollomunichinsurance.com • Website: apollomunichinsurance.com

Apollo Munich Health Insurance Co. Ltd. • 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon-122016, Haryana Tel: +91-124-4584333 Fax: +91-124-4584111
• Corp. Off. 1st Floor, SCF-19, Sector-14, Gurgaon-122001, Haryana • Reg. Off. Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500033, Telangana.
Indian Overseas Bank is an IRDA licensed corporate agent (CA Licence Number: 900847 ) of Apollo Munich Health Insurance Company Limited (“AMHI”). This Insurance policy
is underwritten by AMHI. Participation by the bank’s customers in an insurance product is purely on a voluntary basis. • Insurance is the subject matter of solicitation.
For more details on risk factors, terms and conditions please read sales brochure carefully before concluding a sale. • IRDA Registration Number - 131 • Corporate Identity
Number: U66030AP2006PLC051760