Coverage (tick

Benefit Description wherever applicable) Sum Insured

Critical Illness 17-Listed critical Illness Yes No
30 days Survival Period Applicable Yes No
Personal Accident (AD + PTD) Plan A – 100% of CSI Yes No
Plan B – 100% of CSI + 100% of CSI in case Yes No
of Accidental death whilst travelling
in the listed public carriers
Child Education Benefit – in multiple of Yes No
INR 25000 to max INR 500000
Permanent Partial Disability Yes No
Involuntary Loss of Job Max up to 3 EMI and Applicable for salaried Yes No
individuals only
*Sum Insured under Critical illness and Personal Accident should be equals to loan amount.
UIN: LIBPAGP19038V021819
 Liberty General Insurance Limited Awarded for “Beet Contact Center - 2015” across
10th Floor, Tower A, Peninsula Business Park, BFSI sector in Customer Experience Summit - An Initiative by
Ganpatrao Kadam Marg, Lower Parel, Mumbai - 400 013
Phone: +91 22 6700 1313 Fax: +91 22 6700 1606
Liberty
Email: care@libertyinsurance.in General Insurance
IRDA registration number: 150 • CIN: U66000MH2010PLC209656

Is the proposer or the persons proposed, already insured under or proposed for a loan linked insurance policy with Liberty General Insurance Limited or any other
insurance company? lfyes, please indicate below the Policy/Application number(s) (Please mention application number in case of pending proposal)
Policy No./ Insured Insuranc Fro To Sum Claim Details (if
Application No. Name e m (Date Insure any)
Compan (Date ) d
y )

Do you want us to consider these details for portability? 0 Yes O No

Since when are you continuously insured?

Instrument Type
Name of the Premium Payer Bank Name Cheque Date Amount in INR
(Cash / Cheque / DD / Others)

Please make an A/C Payee Cheque / DD / Pay Order in favor of ‘Liberty General Insurance Limited' only.

1. I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and
complete in all respects to the best of my knowledge and that li\i\ie am/are authorized to propose on behalf of these other persons.
2. I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance
company and that the policy will come into force only after full receipt of the premium chargeable.
3. IMe further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured / proposer after the proposal has
been submitted but before communication of the risk acceptance by the company.
4. I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at any time has attended on the life to be insured/
proposer or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured / proposer and seeking
information from any insurance company to which an application for insurance on the life to be assured / proposer has been made for the purpose of underwriting the
proposal and/orcIaim settlement.
5. I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and / or claims
settlement and with any Governmental and/ or Regulatory authority.

IN CASE THE PROPOSER IS ILLITERATE OR PROPOSAL FORM IS IN A LANGUAGE OTHER THAN THAT UNDERSTOOD BY THE PROPOSER (To be signed
by the person who has explained the contents of the Proposal Form to the Proposer)
I, the declarant/proposer hereby declare and confirm that i have explained/understood the contents of the proposal form in language understood
by proposer/me and proposer has affixed his/her signature/thumb impression on the proposal form only after understanding the contents thereof.
Declarant Name: Proposer name:

Signature: Signature/Thumb Impression:

Submission of Loan Disbursement Letter is mandatory at the time of claim.

The Policy is issued to the borrower/ loanee of the aforesaid Bank/Financial Institution and incepts only when the disbursed loan amount is realized by the loanee and
debited to the financier. The Company will have no liability until the proposal is accepted by the Company and communicated so to the proposer and the inception of cover
would be on receipt of full premium against the proposal and only when the disbursed loan amount is realized by the loanee and debited to the financier. Neither the
submission to us ofa completed proposal for insurance nor any payment for any policy sought obliges us to agree to issue a policy, which decision is and always shall be in
our sole and absolute discretion. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions and we shall have no liability to make any
payment if premium is not received by us in full and on time, or is not realized or non-fulfillment of Pre Policy Check-up. If we do not accept the proposal, we will inform you
and refund any payment received from you without interest within the next30 days.

Date Place '

o 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
renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the Insurer.
1. Any person making default in complying with the provision/s of this section shall be punishable with fine, as may be prescribed under Insurance Act, 1938 or any
amendment thereto for the time being in force.
UIN: LIBPAGP19038V021819

I/We, hereby authorize my Bank/Financier in event so arising to instruct Liberty General Insurance Limited to cancel my policy/policies. Further, in event of any
claim/refund/cancellation, I/We authorize and instruct Liberty General Insurance Limited to refund/pay the amount payable, if any as per the terms & conditions of the
policy, directly to my Bank/Financier on my behalf. I/We have no objection, if Liberty General Insurance Limited pays the amount to my Bank/Financier directly. Balance
amount if any, shall be paid to myself/us/nominee.

I/We, agree and understand that refund of premium by Liberty General Insurance Limited to my Bank/Financier shall absolve Liberty General Insurance Limited from any
and all liabilities arising out of the said policy.
p
I agree and consent to Insurance Company sending the policy documents to my registered email id and/or mobile number.

Dated on this day of at

(Proposer Signature)