I wish to apply for below ticked Insurance and request you to process the application as per details provided

in the form Application date 13/02/2023 .

Credit Protect Sarv Suraksha Motor Insurance

Accidental Insurance plan from HDFC ERGO General Insurance Co.Ltd. for the tenure of 36 months, the premium amount being Rs 1412.0 /- .

I hereby consent that the transaction fee of Rs 1412.0 /- would be deducted from the dealer's disbursement. I hereby authorize HDFC Bank Ltd to pay the premium on my
behalf and the same to be included in my loan amount from the bank and recovered from me in EMI's.

Nominee Details

Title : Mr. Ms. Dr. Applicant Co-Applicant

Applicant Name PRATIK PRAKASH BORDIKAR

Nominee Name MADHURI BORDIKAR

Nominee Relationship SPOUSE

Nominee DOB 15/02/1994 Nominee Gender

Applicant Address Home No3877

(Residence) ChinchaniTarapur Road Near

Landmark Sai Baba Mandir

City THANE PIN Code 401503

MAHARASHTRA India
State Country

- 9987587040
Tel (R/O) Mobile No.

e-mail ID PRATIKBORDIKAR@GMAIL.COM

Name of the Customer

PRATIK PRAKASH BORDIKAR

"Applied, Accepted, Authenticated, Signed and Place: ______________

Delivered by the Borrower through NetBanking
using my NetBanking Customer ID & Password, Date: ______________
by ticking the "I agree" icon on the online
system/NetBanking/Website of HDFC Bank as
well as by entering the one time password
(OTP)" .
 Terms and Conditions

I accept the Terms and Conditions of the insurance policy.

I/We hereby declare on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects to the best of my knowledge
and that I/We am/are authorized to propose on behalf of these other persons.
I understand that the information provided by me will form the basis of 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
I/We 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.
I/we declare and further consent to the company. seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/ proposer or
from any past or present employer concerning anything which affects the physical and 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/or claim settlement.
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.
I authorize HDFC ERGO General Insurance and associate partners to contact me via email, phone, SMS.
I/We hereby declare that I/We not engaged in military service, police, professional sports, mine workers, fire workers, fire fighters, water vessel crew, oil field/oil rig workers, structural
workers, window cleaners, junk/salvage workers, saw mill workers, security guards and similar hazardous occupations or professionals like doctors, Lawyers and politically exposed
personal

It is essential that you answer fully and accurately all the question contained in this proposal, and that you provide us with any and all condition information relevant to the risk to be insured or
our decision as to the acceptance of the risk or the term upon which it should be accepted. Your failure to comply with this obligation now may result in the rejection of your claim and the
avoidance of your policy when a claim is made. If you are in any doubt about the information to be given, please seek the advice of your insurance advisor. The liability of HDFC ERGO
General Insurance Company Ltd DOES NOT commence until THE Company has accepted the proposal and the full premium has been paid. Participation by Financier's customer shall be
purely on voluntary.

The contract of insurance is between HDFC ERGO General Insurance Company Ltd. and the insured and not between Financier and the Financier shall not warranty / guarantee or be liable
for the services provided by HDFC ERGO General Insurance Company Ltd. Financier shall not take responsibility for settlement of claims and HDFC ERGO's decisions in this regard shall be
final. Any grievance with respect to insurance policy/ claims/ settlement shall be taken up with HDFC ERGO General

Insurance Company Ltd. and Financier shall not be responsible/ liable for the same. Customers are requested to read the offer document before taking the insurance. It is at your will to buy
Sarv Suraksha Pro offered by HDFC ERGO. You are at liberty to choose your own insurer for your insurance need.

Insurance Act 1938 Section 41 - Prohibition of Rebates. No person shall allow, either directly or indirectly, as an inducement to any person to take out, renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of the whole part of the commission payable or any rebate of the premium shown on the policy, nor shall any person
taking out or renewing a policy accept any rebate, except such rebate as many be allowed in accordance with the published prospectus or tables of the Insurer. ANYPERSON MAKING
DEFAULTIN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALLBE PUNISHABLE WITH THE FINE WHICH MAYBE EXTENTED TO FIVE HUNDRED RUPEES.

Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer.
Any person who, knowingly and with intent to defraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals for the purpose
of misleading, Information concerning any fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and
result in a denial of insurance benefits.

Name of the Customer

PRATIK PRAKASH BORDIKAR

"Applied, Accepted, Authenticated, Signed and Place: ______________

Delivered by the Borrower through NetBanking
using my NetBanking Customer ID & Password, Date: ______________
by ticking the "I agree" icon on the online
system/NetBanking/Website of HDFC Bank as
well as by entering the one time password
(OTP)" .

"Application is submitted on-line by the customer using his/her NetBanking User ID and password on 13/02/2023 at 03:12 PM through IP Address 172.30.68.35 "
Consent for Transfer into Loan Account Number : 52022TA00029

To,

HDFC ERGO General Insurance Company Limited

I PRATIK PRAKASH BORDIKAR hereby declare, agree and confirm that:

From the Policy Start Date, in the event of any claims becoming payable by HDFC ERGO General Insurance Company Limited (the Company) under Sarv Suraksha Pro Policy (the Policy),
the same shall be deposited by the Company in the loan account number 52022TA00029 held with the "Bank/Financial Institution as named in Schedule of the Policy" without any reference
/ notice to the undersigned, but not exceeding the Principal Outstanding as defined under the Policy.

In the event of any claims payable under the Policy exceeding the Principal Outstanding, the Company shall pay such claim amount exceeding the Principal Outstanding to the undersigned

In consideration of the payment of claim amount under the Policy by the Company in the aforesaid manner, I shall completely discharge the Company from all liability, claims under the Policy
and the same shall be binding on me and my heirs, executors, administrators, successors or legal representatives, as the case may be.

Name of the Customer

PRATIK PRAKASH BORDIKAR

"Applied, Accepted, Authenticated, Signed and Place: ______________

Delivered by the Borrower through NetBanking
using my NetBanking Customer ID & Password, Date: ______________
by ticking the "I agree" icon on the online
system/NetBanking/Website of HDFC Bank as
well as by entering the one time password
(OTP)" .

"Application is submitted on-line by the customer using his/her NetBanking User ID and password on 13/02/2023 at 03:12 PM through IP Address 172.30.68.35 "