Plan: HDFC Life Group Jeevan Suraksha (Micro-Insurance Product)

Sum Assured (INR) 150000 Premium (INR) 1563.00 Cover Term (yrs) 2 Moratorium Period (yrs) 30 days
Premium Payment Option: Regular Single Limited Premium Payment Frequency: Single Yearly Half Yearly Quarterly Monthly
Cover Type: Single Life Joint Life
Main Benefit: Level Interest Rate: %

Particulars of Member: Mr/Mrs.

Date of Birth/Age(yrs):01/01/1984
M A N G A D U D L A S A I D U L U
Address: H no 2 14 AKKENAPALLY VARE
Gender: Male
LINGOTAM,NARKETPALLY,Nalgonda,Telangana,508254

Particulars of Joint Life Assured(if any): Mr/Mrs. Date of Birth/Age(yrs):

Loan
Relationship Loan Account No:
Gender: None Type:
with Member: 240136617511
TW

Particulars of Legal Guardian (if Member / Joint Life Assured is a minor): Mr/Mrs.

Relationship with Member /

Date of Birth/Age(yrs): Gender:
Joint Life Assured:

Nominee / Appointee Details:

Name Date of Birth Gender Contact No. Relationship to

Nominee: PADMA 01/01/ 1988 TG 8309152419 Wife
Appointee:

DECLARATION OF GOOD HEALTH

1. Are you in sound state of health? Yes NO

2. Have you ever undergone, or expect to undergo any surgical procedure for any illness, ailment, disease or disability? Yes NO
3. Have you ever suffered from, or are suffering from any disease/ailment requiring any form of medication for more than 7 consecutive days,
or been absent from work for more than 7 days? Yes NO

For Female Lives only :

1. Are you pregnant now? Yes No

2. If response to Qn(1) if yes, please mention how many weeks (Please attach pregnancy questionnaire)
3. Have you ever suffered from any disease of the breast, uterus, cervix, ovaries or any other part of the reproductive system? Yes No

II Do you engage or intend to engage in any business, sport or occupation of a hazardous nature? Yes No
III Do you have any history of conviction under any criminal proceedings in India or abroad? Yes No
IV Have any proposal for insurance, or revival of policy on your life to this company or any other insurance company been
postponed/declined/accepted on terms other than proposed? Yes No

PAYMENT AUTHORISATION (if applicable) I do hereby declare that I have received a loan from M/s "TATA CAPITAL LTD"
(“Master Policyholder”). In order to secure the said loan I have taken the above referenced policy from HDFC Standard Life Insurance
Company Limited (“HDFC Life”). In consideration of receiving the said loan I hereby authorize HDFC Life to make payment of
Outstanding Loan Balance amount to Master Policyholder by deducting from the claim proceeds payable on happening of the
contingent event covered by the Group Life Insurance Scheme/ Policy referenced above.
Signature/Thumb impression of Witness*:
Signature / Thumb Impression of the Insured Member:
VEMULAKONDA KRISHNA
Name &Address :
VEMULAKONDA KRISHNA& SY NO 1475 , WARD NO 6 , BLOCK NO.9 , , , NALGONDA , , Nalgonda, Telangana, ,
<br>India
Occupation: CRE - Salaried Date and Place: 18/1/2024 Nalgonda

* Witness Signature, Address and Occupation is along with signature of Insured Member

Declaration to be made by a 3rd person where: a) The Member has affixed his/her thumb impression; OR b) The Member has signed
in vernacular; OR c) The Member has not filled the application.

I hereby declare that I have explained the contents of this application form to the Member in English language and have truthfully recorded the
answers provided to me. I further declare that the Member has signed/affixed his/ her thumb impression in my presence.

Signature / Thumb
Signature/Thumb impression of Witness* Signature / Thumb Impression of
Impression of the
VEMULAKONDA KRISHNA the Joint Life Assured^ (if any)
Member^
Name & Address:
VEMULAKONDA KRISHNA& SY NO 1475 , WARD NO 6 ,
BLOCK NO.9 , , , NALGONDA , , Nalgonda, Telangana, , <br>India
Date & Place:
Date & Place: 18/1/2024 Nalgonda Occupation: CRE - Salaried
18/1/2024 Nalgonda

* Witness Signature, Address and Occupation is required along with signature of Member

Declaration made by Member: I hereby declare that the content of the form and document has been fully explained to me and I have fully
understood the significance of the proposed contract.

Signature / Thumb Impression of the Joint Life Assured

Signature / Thumb Impression of the member
(if any)

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor: I hereby declare that the content of the form
and document filled up by the Member or Joint Life Assured is accurate and true to my knowledge.

Signature / Thumb Impression of the Signature Signature / Thumb Impression of the

Legal Guardian (if Member is a Minor) Legal Guardian (if Joint Life Assured is a Minor)

Note: PLEASE DO NOT SIGN BLANK FORM

NAME:
M A N G A D U D L A S A I D U L U

EMAIL:
m a n g u d l a s a i d u l u @ g m a i l . c o m

MOBILE NO.: 8 1 2 5 6 3 7 2 6 9 DOB: 0 1 0 1 1 9 8 4

CUSTOMER DECLARATION

I hereby agree to buy CPP Card Protect Lite at the price mentioned above. I understand that CPP CPP Card
Card Protect Lite is a product provided by CPP Assistance Services Pvt. Ltd. (CPP) and the
services provided to me will be subject to the terms and conditions of CPP Card Protect Lite. I Protect Lite
hereby give my consent to CPP to contact me through phone, post or email for the purpose of 1,099
activation and provision of services of CPP Card Protect Lite. Tata Capital Limited (TCL) and/or (inclusive of
its parent/ subsidiaries shall in no way assume any responsibility for any product or services
offered by CPP. taxes)
I am aware that availing this plan/ package/ service is optional and not connected with the loan
or any other service of TCL in any manner. I hereby agree that if for any reason whatsoever TCL
is unable to recover any payment required to be made to CPP or the required charges to be paid
in accordance with the product/ service, no liability will be attached to TCL and the product/
service shall not be provided to me until such payment is made to CPP. I hereby authorize CPP Customer Signature
to cancel my CPP Card Protect Lite membership, upon instruction received by CPP from TCL in
the event I default on the repayment of the finance facility availed by me from TCL.