Health Questions: 1 (Question to be asked for sum assured above USD 50,000 only)

a) Has your weight changed by more than 5 kgs in the last 12 months? Yes No
If yes, give details:

b) Have you been advised to undergo any surgery or medical procedure, or do you intend to seek medical opinion in the next 3 months? Yes No
If yes, give details:
c)Please provide details of the doctor/clinic /hospital you are visiting for your wellbeing

Pl1.1 For Females: (Question to be asked if customer is a female only)

a) Are you currently pregnant? Yes No
If yes, state duration of pregnancy in weeks

b) Have you ever had complications at child birth? Yes No

If yes, give details

c) Have you suffered or are you suffering from any gynecological problems? Yes No
If yes, give details

1.2. Family and Medical History : Give details on the state of health and full particulars of any major illnesses. (Question to be asked only if Sum assured
above USD 50,000) only – Option to provide only one relative at a time.

Relation Age as on Last Birthday/ Health Status Age at onset of disease Cause of death (if deceased)
Age at Death (if deceased)
Father

Mother

Brothers

Sisters

1.3 Details of other Life/Health Assurances: (If the answer is yes to any of the following questions, please give appropriate details.).

a)Has any proposal for life insurance, critical illness or disability cover on your life been made within the last 24 months or are you currently applying
for life insurance, critical illness or disability cover with any other Company? Yes No

b) Do you have any existing life insurance, critical illness or disability cover? If Yes, please complete the details below: Yes No
S. No. Company Name Sum Covered Policy Term Reason for Cover

c) Has any proposal for life insurance, critical illness or disability cover on your life ever been postponed, declined, or accepted with extra premium or on
special terms? Yes No

1.4 Lifestyle Questions about the Life to be Assured

(If the answer is yes to any of the following questions, please give appropriate details.)
a) Height in ______ cms b) Weight in _______ kgs c) Waist Circumference ______ in Inches Yes No

d) Do you smoke?
If yes provide details of units per day
If you are an ex-smoker please let us know when you stopped smoking (MM/YY)

e) Do you drink alcohol? Yes No

If yes, please state your average daily consumption and type of liquor consumed.
f) Have you ever been advised to give up tobacco and/or alcohol for a specific reason?
Yes No

d) Have you ever taken drugs other than those prescribed by a doctor? Yes No

e) Do you or are you likely to engage in an occupation or any activity which could be considered dangerous (e.g. aviation, other than as a fare paying passenger,
commercial pilot or airline steward(ess) on a regular route, or motor racing, diving or any other dangerous sport)? Yes No

f) Have you in the past 5 years remained absent from your place of work due to accident or illness for a continuous period of 7days or more? Yes No

g) Have you undergone any surgical operation or any investigations such as but not limited to ECG, blood test, biopsies, MRI, CT scan etc.?

Yes No

h) Are you currently a member of any armed forces? Yes No

i) Have you travelled outside the current country of residence in the last 12 months for holiday or occupation, other than your home country?

If yes, please give details including specific countries visited and duration of stay in each country Yes No

j) Do you intend to travel outside the current country of residence in the next 12 months for holiday or occupation, other than your home country?

If yes, please give details including specific countries to be visited and duration of stay in each country Yes No

1.5 Health Questionnaire: (if yes give details)

Have you ever suffered from or are you currently suffering from or have you ever been treated for:

a) Diabetes, high blood sugar? Yes No

b) Hypertension, high blood pressure, heart attack, chest pain, stroke, murmur, any disorder of the heart or blood vessels? Yes No

c) Any form or type of cancer, tumor or cyst? Yes No

d) Respiratory or lung problems i.e. asthma, bronchitis, persistent cough, tuberculosis etc.? Yes No

e) Any disorder of the digestive system, gall bladder, pancreases, intestine or liver i.e. actual or suspected gastric or duodenal ulcer, bleeding from the bowel,
recurrent indigestion, hepatitis, gallstones, hernia etc.? Yes No

f) Any disease, disorder or infection of the kidneys, bladder or reproductive organs i.e. blood/ protein in urine, kidney stones, prostatitis, venereal disease etc.?
Yes No
g) Any disorder or disease of the muscles, bones, joints, limbs or spine (including arthritis, rheumatism, slipped disc, paralysis etc.)? Yes No

h) An anxiety state, depression or any mental, nervous or neurological disorder? Yes No

i) Any disorder of the blood i.e. anemia, thalassemia etc.? Yes No

j) Any defect of the vision, speech or hearing? If ‘Yes’ state to what extent. Yes No

k) Have you ever received treatment with blood products or undergone a blood transfusion? Yes No

I) Any illness, injury, disability not mentioned above? Yes No

m) Are you presently taking medication of any kind? Yes No

n) Are you in good health and free from any defect or deformity? Yes No

None of the above

Remarks (if Yes selected in any of the above)

Section 2(To be filled in all applications)
4.0 Are you a Politically Exposed Person*? Yes No
*Politically Exposed Person is an individual who is or has been entrusted with a prominent public function, or a relative or a known associate of that person

4.1 Are you a resident of the United States of America for tax purposes or if are you a United States citizen or Green cardholder: Yes No
(If yes) Please provide Tax Identification Number:

Please submit the Foreign Account Tax Compliance Act (FATCA) form

Section 3 Occupation &Income Details (To be filled in all applications)

Occupation : Salaried Self Employed/ Business Owner Housewife Student Others (please specify)

If Housewife, please provide spouse's individual life insurance details in USD

Designation : Nature of Duties :

Employer/ Business Name :

Purpose of Insurance: Industry:

Income Details (for the last 2 years):

Year _____ Year_____

(Amount with Currency) (Amount with Currency)
Salary
Income from Business
Dividends
Bonus/ Commission
Share of Profit
Other Sources
Grand Total

Declaration: I hereby declare that I have personally read and answered each of the above questions and that all statements and answers to the above
questions are complete and true to the best of my knowledge and belief, I agree that they shall (together with any additional forms/ attachments) form a
part of any policy contract that may be issued on the strength thereof. If any untrue statement be contained therein the contract of insurance shall be
absolutely null and void and all money paid in respect thereof shall be forfeited to the Company.

I hereby authorize any hospital, physician or other person who has attended to me or may in the future attend to me, to give HDFC International Life and Re or its
representatives all knowledge and information which was thereby acquired, including the history obtained and diagnosis made. I irrevocably permit HDFC
International Life and Re to make relevant disclosures to any such authorities without obtaining further written or oral permission from me. I agree that no
insurance shall take effect unless I am in good health when the first premium is paid.

I, hereby authorize HDFC International Life and Re to share my personal details with related parties for issuing my policy and settlement of claims . The insurance
cover shall start only after the issuance of policy by HDFC International Life and Re.