Membership Form cum Declaration of Good Health

IMPORTANT NOTE : Any additional text written or qualification given in the form would make it invalid.

Name of the Policyholder : Kotak Mahindra Bank Ltd. Policy Number : GO000036

Product Name : Kotak Group Secure One Product UIN No.: 107N098V05 Plan Option : Easy Secure

Riders Opted:

Kotak Critical Illness Plus Benefit Rider (107B015V05): YES NO

Kotak Accidental Death Benefit Rider (107B005V05): YES NO

Kotak Accidental Disability Benefit Rider (107B008V03): YES NO

Mr. / Ms. : SIYARAM MEENA

Gender: Male Female Transgender

Unique Identification Number : 640680128 CoverAmount opted for: 10,00,000/- Customer ID: 640680128

Rider Name Rider Sum Assured

Cover Amount for Kotak Critical Illness Plus Benefit Rider (107B015V05) N/A
Cover Amount for Kotak Accidental Death Benefit Rider (107B005V05) N/A
Cover Amount for Kotak Accidental Disability Benefit Rider (107B008V03) N/A

NOMINEE DETAILS

Name : NIKITA MEENA

Relationship to Life to be Insured : Sister

*Nominee needs to be a major i.e. above 18 years of age and should be one of the following: Husband, Wife, Son, Daughter, Father, Mother, Brother, Sister, Grandfather or Grandmother.

*Incase of Nominee being a Proprietor/Partnership Firm/Limited Company the above condition would not apply.

DECLARATION OF GOOD HEALTH

I hereby declare that :

1.I have not been hospitalized for 7 days or more within the past two years due to any illness and have not suffered within last 3 years or currently not suffering fromserious diseases such as Cancer; Heart Problem; Chest

Pain; Stroke; Paralysis; Diabetes; Kidney Problem; Liver Problem; Lung Disease; Nervous Disorder, psychiatric illness or anyother critical illness; HIV infections / AIDs or any other Sexually Transmitted Disease

2.I am in good health and I have not experienced any flu like symptoms (Like fever, cough, shortness of breath etc.) and neither been advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus (SARS-

CoV-2/COVID-19) nor, I am awaiting the result of a test which has already been submitted for the novel coronavirus (SARS-CoV-2/COVID-19) in last 1 month

3.The above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Kotak Mahindra Life Insurance Ltd.[KLI]. if any untrue statement be

contained herein, Kotak Life Insurance has the right to reject the benefits/Claim

Signature / Right Thumb impressions of life to be insured

Place : <<Digitally Authenticated by the customer using Kotak Banking Applications / Voice call from Kotak Mahindra Bank Limited >> 640680128-24/09/2023-09:30 PM
DECLARATION BY LIFE ASSURED / PROPOSER WHERE SCRIBE IS INVOLVED

I hereby declare that the contents of the form and documents have been fully explained to me and that I have fully understood the significance of the proposed contract

Place : NA Date : NA Signature of the Life Assured/Proposer : NA

DECLARATION WHERE SCRIBE IS INVOLVED (COMPULSORY FOR ALL DECLARATIONS SIGNED IN ANY VERNACULAR LANGUAGE)

I ___________ _______________________ (full name of scribe) have explained to the member the contents of this form in his own language and he/ she has fullyunderstood the same,. Also, I have explained that if any

untrue statement is contained herein, the member, and/or the heirs, executors, administrators, assignees of the member shall not be entitled to receive any benefits, including, inter alia, benefits under any insurance policy

procured on the faith of this Form.

Place : NA Date : NA Signature of the Scribe : NA

Place : NA Date : NA Witness / Policyholder Authorized Signatory : NA

Section 41 of the Insurance Act, 1938 states: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew 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 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 published prospectuses or tables of the insurer.
Section 45 of the Insurance Act, 1938 States: The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above contract. Please refer to Section 45 either on our website or contact our intermediary or

visit the nearest branch for the full text.

https://kotaklife.com/assets/images/uploads/why_kotak/section38_39_45_of_insurance_act_1938.pdf Free Look Period: The member is offered 15 days free look period from the date of receipt of the Certificate of

Insurance wherein the Member may choose to return the Certificate of Insurance within 15 days of receipt if s/he is not agreeable with any of the terms and conditions of the plan and receive the applicable refund amount.

Kotak Mahindra Life Insurance Company Ltd.;CIN: U66030MH2000PLC128503, Regn. No.: 107, Regd. Office: 8th Floor, Plot # C- 12, G- Block, BKC, Bandra (E),Mumbai- 400 051. Website: https://www.kotaklife.
com; Email:kli.groupoperations@kotak.com. Toll Free No. â 1800 120 7856

Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.