HDFC ERGO General Insurance Company Limited

Optima Restore
Proposal Form

Application No___________________________________

1. Please fill the form in BLOCK LETTERS.

2. Please answer all the questions fully and correctly. If a particular question is not applicable to you, please mark that question as
Not Applicable “N/A”.
3. The Company’s liability does not commence until the acceptance of the proposal has been formally intimated to the Policyholder
and full premium has been realized by the Company.

The Company’s liability does not commence until the acceptance of the proposal has been formally intimated to the Policyholder and full premium has been
realized by the Company.

Intermediary Code Intermediary Name Intermediary Number

Proposer Details

Name of the Proposer:

Address:

Date of Birth: Nationality:

D D M M Y Y Y Y

Residential Status: � Resident Indian � NRI

GSTIN / UIN (if any): CKYC No.:

Is the proposer a Politically Exposed Person? � Yes �No

Note: Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country, including the
heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned corporations
and important political party officials

City/Town: District:

State: Telephone:

Email:

Marital Status: PAN No.:

I have eIA (Y/N): � Yes �No I would like to apply for eIA: Karvy� CAMS� NSDL� CDSL�

Annual Income : � 0-2.5 lakh � 2.5 - 5 lakh � 5 - 15 lakh � 15 - 20 lakh � 20-30 lakh � 30 lakh and above
Education Level:

Occupation: Salaried� Self-employed� Business Owner� Student� Housewife� Retired�

If others, please select source of income whichever is applicable: � Rentals � Interest � Pension � Investment
Industry Type: � Jewellery � Import-Export � Mining � Shipping � Scrap Dealing � Agriculture � Stock Broking
� BFSI � Real Estate � Manufacturing � if Others, please specify ________________________________________

Employee ID (Employees of HDFC Limited Group and Munich Re Group)

Policy Number of any active HDFC ERGO Policy where you are the Policyholder

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 1
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 Details of the Person(s) Proposed to be insured
Basic Date Relationship Politically ABHA
S. Mobile Gender Height Weight
Name Sum of with Exposed ID (if
No No. (M/F/TG) (in cms) (in kgs)
Insured Birth Proposer person (Y / N) available)
1
2
3
4
5
6

Note:
• In case any insured person(s) wish to generate his/her ABHA ID. Kindly visit the link: [Link]

Premium Tier (Please Tick)

Tier 1 � Tier 2 �
Classification of Cities for Premium Tier

• Tier 1: Delhi, National Capital Region (NCR), Mumbai, Mumbai Suburban, Thane and Navi Mumbai, Surat, Ahmedabad and Vadodara.

• Tier 2: Rest of India

No co-payment shall apply if Insured Person from Tier 2 avails a treatment in Tier 1.

Nominee Details
Name of Person Proposed to be insured Name of Nominee Relationship Address of the Nominee

Where Nominee is a minor, please give the details of Appointee

Name of the Appointee Relationship to Nominee Address of the Appointee

Note: The nominee must be an immediate relative of the Proposer. Nominee for any of the persons proposed to be insured shall be the Proposer.

Policy Details

Policy Type Individual � Family Floater �

Tenure 1 Year � 2 Year � 3 Year �

Policy Period From ________________________ To ________________________

Sum Insured in `

3 Lakhs � 5 Lakhs � 10 Lakhs � 15 Lakhs �

20 Lakhs � 25 Lakhs � 50 Lakhs � 100 Lakhs �

Optional Covers

S. No. Optional Cover Description

1 Unlimited Restore Benefit � Unlimited restorations in a policy year

2 Aggregate Deductible � � Rs.25,000 � Rs.50,000 � Rs.1,00,000

3 Co-payment � � 10% � 20%
Notes pertaining to optional covers

a. Coverage for Unlimited Restore benefit and Aggregate deductible shall be on Individual basis if the base plan is on individual sum insured basis OR on floater basis
if the base plan is on floater sum insured basis.

b. Co-payment shall be applicable on per claim basis

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 2
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 c. Aggregate deductible can be chosen on all or none basis at policy level

d. Co-Payment can be chosen on all or none basis at policy level

Add-On Covers
Plan 1 Plan 2 Plan 3 Plan 4
my: health Critical Illness (9 Illnesses ) (12 Illnesses) (15 Illnesses) (18 Illnesses)
(You can opt for a Sum Insured from 1 Lakh to 500
1 Plan 5 Plan 6 Plan 7
Lakhs)
(25 Illnesses) (40 Illnesses) (51 Illnesses)
2 Individual Personal Accident Rider �Yes �No
3 Protector Rider �Yes �No
4 Hospital Daily Cash Rider (Maximum upto 30 days) �₹1,000 / day �₹2,000 / day �₹3,000 / day
5 Critical Advantage Rider �USD 2,50,000 �USD 5,00,000
6 Optima Wellbeing (Add on) �Yes �No

Add-on cover details table

my: health Critical Hospital Daily IPA Rider Critical Advantage Optima
S. Protector Rider
Name Illness Sum Cash Rider per day Sum Insured Rider Sum Wellbeing (Add
No. (Yes/No)
Insured (INR) Sum Insured (INR) (INR) insured (US D) on) (Yes/No)
1
2
3
4
5
6

Notes pertaining to Add-on covers

a. Coverage for my:health Critical Illness, Individual Personal Accident Rider, Critical Advantage Rider shall be on Individual Sum Insured basis only.
b. Coverage for Protector Rider, Hospital Daily cash Rider shall be on Individual basis if the base plan is on individual sum insured basis OR on floater basis if the
base plan is on floater sum insured basis.
c. my: health Critical Illness add-on can be opted by adults (persons over 18 years of age) only
d. Critical advantage rider will be offered only if base policy Sum Insured is ₹10 lacs & above. This rider can be opted by adult dependent only if primary insured
also opts for the same. Incase of dependent children and dependent parents rider can be opted on all or none basis.
e. Sum Insured under Individual Personal Accident rider will be 5 (five) times the Sum Insured of Optima Restore (Base Plan) up to a maximum of ₹1 Crore and this
rider will be offered only to the Proposer when he/she is covered in the Base plan.

Other items

� Go Green and make a difference to our planet! We shall provide you with soft copy of your Policy at your registered e-mail id.
Note: Soft copy of your policy can be easily accessed at your fingertips to refer to terms and conditions, for lodging claims and for any other service needs.

¨ Additionally, by ticking the check box we understand that you wish to have a physical copy of your policy.
For details on the process to receive your physical policy kindly visit “Help” section on [Link] or contact our customer care for the same

Existing/Previous Insurance Policy Details

Does any person proposed to be insured presently hold any Health Insurance/Critical Illness Insurance Policies from HDFC ERGO or any other Insurer?

If Yes, please provide below details

Period of Insurance Claims lodged during To be

Policy No. / Name of the Name of the Sum
the preceding years considered for
Application No. Insured Insurer DD/MM/YYYY To DD/MM/YYYY Insured
(Y/N) continuity (Y/N)

Please note that continuity of benefits shall NOT be considered if the above question of want of continuity is not replied affirmative, details are not provided and Portability
form / Migration details and relevant supporting documents are not submitted.

If No, please tick below declaration:

� I/We hereby declare on my behalf and on behalf of all persons proposed to be insured that I/We do not hold any Health Insurance / Critical Illness Policy from
HDFC ERGO or any other insurer.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 3
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 Medical and Lifestyle Information
(Please provide information in the same order as mentioned under Proposed Persons to be insured)

MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED

[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 1
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No

ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 4
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us:

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED

[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 2
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No

ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 5
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 6
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

4. Has been advised investigation or further tests � Yes � No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests:
Type of tests:
Findings of tests:
Please upload the investigation tests results

5. Was hospitalized in past � Yes � No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Please share details of your past medical condition

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 7
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED
[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 3
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No
ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 8
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

4. Has been advised investigation or further tests � Yes � No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests: Type of tests:
Findings of tests:
Please upload the investigation tests results

5. Was hospitalized in past � Yes � No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Please share details of your past medical condition

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 9
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED
[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 4
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No

ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 10
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

4. Has been advised investigation or further tests � Yes � No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests: Type of tests:
Findings of tests:
Please upload the investigation tests results

5. Was hospitalized in past � Yes � No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Please share details of your past medical condition

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us:

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 11
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED
[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 5
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No
ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 12
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

4. Has been advised investigation or further tests � Yes � No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests:
Type of tests:
Findings of tests:
Please upload the investigation tests results

5. Was hospitalized in past � Yes � No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Please share details of your past medical condition

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 13
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 MEDICAL & LIFESTYLE QUESTIONS FOR PERSON PROPOSED TO BE INSURED
[TO BE REPEATED FOR EACH PERSON PROPOSED TO BE INSURED]
INSURED 6
Please select Medical Question for<name of the person proposed to be insured>
1. Has an ailment or disability or deformity including due to accident or congenital disease � Yes � No
2. Has planned a surgery � Yes � No
3. Takes medicines regularly � Yes � No
4. Has been advised investigation or further tests � Yes � No
5. Was hospitalized in the past � Yes � No
6. Is Pregnant � Yes � No
7. Are you having any disability/ deformity including accidental or congenital? � Yes � No

ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]

1. Has an ailment or disability or deformity � Yes � No. If Yes, please provide the below details
Please tick additional information about your ailment for
� Hypertension/ High blood pressure
� Diabetes/ High blood sugar/Sugar in urine
� Cancer, Tumour, Growth or Cyst of any kind
� Chest Pain/ Heart Attack or any other Heart Disease/ Problem
� Liver or Gall Bladder ailment/Jaundice/Hepatitis B or C
� Kidney ailment or Diseases of Reproductive organs
� Tuberculosis/ Asthma or any other Lung disorder
� Ulcer (Stomach/ Duodenal), or any ailment of Digestive System
� Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
� HIV Infection/AIDS or Positive test for HIV
� Nervous, Psychiatric or Mental or Sleep disorder
� Stroke/ Paralysis/ Epilepsy (Fits) or any other Nervous disorder (Brain/ Spinal Cord etc.)
� Abnormal Thyroid Function/ Goiter or any Endocrine organ disorders
� Eye or vision disorders/ Ear/ Nose or Throat diseases
� Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone/ Joint/ Ligament/ Cartilage
� Any other disease/condition not mentioned above

(i) Please share details for your ailment if exact diagnosis is Hypertension/High Blood pressure
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? � Yes � No
Are you taking Anti-Hypertensive Drugs? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(ii) Please share details for your ailment if exact diagnosis is Diabetes / High blood sugar / Sugar in urine
Exact Diagnosis: � Type 1 DM/IDDM � Type 2 DM � GDM (Gestational Diabetes)
Are you taking insulin? � Yes � No
Diagnosis Date: Consultation Date:
Hospital Name:    

(iii) Please share details for your ailment (except for Diabetes and Hypertension)
Exact Diagnosis: Diagnosis Date:
Treatment type: � Medical � Surgical
Complications / Recurrence: � Yes � No
Current status: � Pending Treatment � Ongoing Treatment � Cured � If others, please specify ______________________________
Biopsy report:   � Malignant � Non-Malignant � Not Applicable
Consultation Date:
Hospital Name:
Please share details of your treatment:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 14
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 2. Has planned a surgery � Yes � No. If Yes, please provide the below details
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Proposed Surgery:
Please share details of your past surgery <name of the person proposed to be insured>

3. Takes medicines regularly �Yes �No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
(i) If exact diagnosis is Hypertension then please provide details of the below questions
Exact Diagnosis:
Are you taking any anti-platelets/anti-coagulants/Blood thinning agents/Anti Lipids? �Yes �No.
Diagnosis Date: Consultation Date:

(ii) If exact diagnosis is Diabetes then please provide details of the below questions
Exact Diagnosis:
Takes insulin �Yes �No.
Diagnosis Date: Consultation Date:

(iii) If exact diagnosis is other than Hypertension and Diabetes please provide details of the below questions:
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Medicine Name:
Please share details of your treatment <name of the person proposed to be insured>

4. Has been advised investigation or further tests � Yes � No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests: Type of tests:
Findings of tests:
Please upload the investigation tests results

5. Was hospitalized in past � Yes � No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:
Diagnosis Date: Consultation Date:
Hospital Name:
Please share details of your past medical condition

6. Is Pregnant � Yes � No. If Yes, please provide the below details

Please share your expected delivery date with us

7. Are you having any disability/ deformity including accidental or congenital? � Yes � No.
If Yes, Kindly tick the specific boxes that are applicable:
� Amputation � Musculoskeletal / Locomotor � Neurological / Cerebral Palsy � Polio � Spinal cord
� Stroke � Visual / Hearing disability � Others
Kindly provide a detailed description for all boxes ticked above: ____________________________________________________________

LIFESTYLE QUESTIONS [RELEVANT SECTION TO BE FILLED]

[TO BE FILLED ONLY IF my: health Critical Illness add-on is opted]

� Cigarette(s) Per Day_____PerWeek_____Per Month_____ since past ______ years

� Bidi(s) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Tobacco Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Gutka Pouches Per Day_____PerWeek_____Per Month_____ since past ______ years
� Alcohol (Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years
� Drugs_(Quantity) Per Day_____PerWeek_____Per Month_____ since past ______ years

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 15
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 Payment Details

Premium Details: Amount Rs.

Premium Payment Options –Single/Monthly / Quarterly / Half Yearly / Annual
Premium Payment Options - Cheque / DD / Card /ECS/Wallet
Instrument Details:________________ Date________________

For refund (Excess Premium/PPC reimbursement) and for payment of claims credited directly into your
bank account

Please provide the following bank details and a copy of a Cancelled Cheque for direct credit into your bank account:

Cheque No Name as in Bank Account

Bank Name Bank Account No
Branch Name IFSC Code
Cheque Date MICR Code
Cheque Amount for `

Note:
1. The Proposer agrees and undertakes to intimate in writing to HDFC ERGO about any change in bank account details.
2. Cancelled Cheque should be of the same bank account in which the refund needs to be credited directly
3. Name on Cancelled Cheque should match with Proposer Name to ensure smooth refund / claim processing
4. If ECS is selected, please submit the standing instruction form available at our branches.

Declaration, Consent & Warranty on behalf of all Person(s) proposed to be insured

■ 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 including the minor/s insured, if any.

■ I/ We understand that the information provided by me/ us 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 to 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 Insurance Company.

■ I/We declare and further consent to the Insurance Company to seek medical and other relevant information from any 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 and mental health of the life to be assured/proposer and
seeking information from any insurance company to which an application or insurance on the life to be assured/proposer has been made for the purpose of underwriting
the proposal and /or claim settlement.

■ I/ We declare and provide my unconditional consent that, pursuant to a claim filed by me/ us, the Insurance Company can seek medical and other relevant information/
documents for me/ us from any Doctor and/ or Hospital where I, or other Insured, had taken treatment i.e. OPD and/ or hospitalization etc.

■ I/We authorize the Insurance Company to share information pertaining to my proposal, including the medical records for the sole purpose of proposal underwriting and/
or claims settlement.

■ I/ We authorize the Company to process my/ our Personal and Sensitive information for profiling purposes and contact me/ us for (i) ensuring timely renewal of the Policy,
(ii) upsell and/ or cross sale of other insurance products which may be found suitable.

■ I/ We authorize the Insurance Company to share my/ our Personal Information and other relevant records details with (i) the Law Enforcement Agencies, as and when
demanded and (ii) any other vendor as per the requirement etc. like printing the Insurance policy/ renewal reminders or any other such activity.

■ I/ We authorize the Insurance Company to share my/ our Personal Information and/ or medical Information/ records with any Government and/ or Statutory authorities/
bodies, as and when demanded, including but not limited to Insurance Regulatory and Development Authority of India (IRDAI), Insurance Information Bureau (IIB) and/
General Insurance Council etc.

■ Customer Satisfaction Surveys: I/ We hereby consent to the Insurance Company to use and share my/ our Personal Information with the vendors for the purpose of
conducting customer satisfaction surveys and related activities aimed at improving service quality and enhancing the overall customer experience.

■ Ayushman Bharat Health Account (ABHA) Declaration : I/We provide my/ our consent to access my/ our (all insured) medical and personal records/ details, as are
available in my/ our Ayushman Bharat Health Account (ABHA) and share the same with Third Party Administrators, Reinsurer (if applicable), Service Provider/s of HDFC
ERGO and/or with any Governmental and/or Regulatory authority for the sole purposes of underwriting my/ our proposal and/ or for checking the authenticity of claims
lodged by me/ us and/ or to comply with the applicable Law/ Regulations.

■ I hereby grant consent to Agent/Broker/Corporate Agent or any other licensed intermediary to share my KYC (Know your Customer) and customer due diligence
information with HDFC ERGO General Insurance Company Limited for the purpose of my insurance proposal.

Signature of the Proposer Date: __________________________________

Time: __________________________________ Place: __________________________________

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 16
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 I/We hereby consent that, in all the above scenarios, my/ our Personal Information and the medical documents etc. can be shared, and/ or
accessed, as the case may be, without any intimation to me/ us.
Note: The liability of the company does not commence until the acceptance of the proposal has been formally intimated by the insured and full
premium has been realized by the company.
We are under no obligation to accept any proposal for insurance. The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO
General Insurance Company Limited along with the premium payment does not tantamount to the acceptance of the Proposal for insurance by
HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of the Proposal for
insurance shall be at the Company’s sole and absolute discretion and upon full realization of the premium payment .In the event of acceptance
of the Proposal for insurance by HDFC ERGO General Insurance Company Limited, such acceptance shall be specifically intimated to the
Proposer by HDFC ERGO General Insurance Company Limited along with the date from which the insurance Cover shall become effective.
HDFC ERGO General Insurance Company Limited shall not be liable for any claim in respect of an event giving rise to a claim covered under
the Policy of Insurance that has occurred prior to policy issuance is not covered under this policy (Your proposal form will be considered after
HDFCERGO General Insurance Company Limited receives premium payment.)
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 fraud the insurance company or any
other person, files a proposal for insurance containing any false information, or conceals or 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.
Anti-Rebating Warning: As per Section 41 of the Insurance Act 1938,as amended, the practice of rebating is prohibited, as follows: No 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 policy in
respect to 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 prospectus or tables of the insurer. Violation of Section41 of the Insurance Act 1938, as amended,
shall be punishable with a fine which may extend to Rs.10Lakhs.

Vernacular Declaration

Declaration in case the proposal is filled other than the Proposer/the proposer sign in vernacular language/proposer is illiterate (to be certified by someone other than an
agent/employee of the company)

(The content of this form and its particulars have been explained by me in vernacular to the Proposer who has understood and confirmed the same.)

Name of the Translator: __________________________________________________________________ Signature of the Translator _________________________

Place ______________________________ Date __________________________

Name of the insured: _____________________________________________________________________ Signature of the insured: _________________________

Place ______________________________ Date __________________________

Acknowledgement Customer Copy

Received from Mr. / Ms. / Mrs

Cheque No: _______________________________________________________________ Cheque Date: _________________________________

Drawn on Bank for a sum of ` _________________towards payment of premium on behalf of HDFC ERGO General Insurance Company Ltd.

Date: _____________________________ Signature & Seal: ______________________

Neither the submission to us of a 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 in time, or is not realized. If we do not accept the proposal, we will inform you and refund any payment
received from you without interest within next 30 days.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 17
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.
 Intermediary Declaration

I, ------------------------------------------------------------------------------------------------------------------------------------------------(Full Name) in my capacity as an Insurance Advisor/

Specified Person of the Corporate Agent/Intermediary/Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of
this Proposal Form, Including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and response(s) submitted
by him/her in this Proposal Form to questions contained herein or any details sought here in will form the basis of the Contract of Insurance between the Company and
the Proposer, if this Proposal is accepted by the Company for issuance of the Policy. I have further explained that if any untrue statement(s)/information/response(s) is/
are contained in this Proposal Form/ including addendum(s), affidavits, statements, submissions, furnished/ to be furnished, the company shall have the right to vary the
benefits which may be payable and further more if there has been a non-disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal may be
treated by the Company as null and void and all premiums paid under the Policy may be forfeited to the company.

Signature of Intermediary Date: __________________________________

Time: __________________________________ Place: __________________________________

Check List

Please check the following documents are attached along with the proposal form

1. ID Proof : Passport / Pan Card / Voter ID / Driving License / Letter from a recognized public authority

2. Proof of residence : Telephone Bill / Bank Account Statement / Letter from any recognized public authority Electricity Bill / Ration Card

3. Age Proof : Proof of Age or proof of having Aadhaar

4. Renewal notice with claim details

5. Photocopies of all previous policies and endorsements

6. Income proof documents [To be provided only if my: health Critical Illness add-on cover is opted]

• ITRs for last 2 FY

• Salary slips for last 3 months

For Office Use Only

Intermediary Code: _______________________________________________________________ Branch Location: ________________________________________

Signature of Intermediary: _________________________________________________________

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Customer Experience Management, Customer Happiness Center: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400
078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on [Link] for policy copy/tax certificate/make changes/register & track claim or simply text 18
“Hi” on what’s app number 8169 500 500 for instant policy servicing. UIN: Optima Restore - HDFHLIP25012V082425 | Product Code: HE/RL/Health/24-25/250.