PROPOSAL FORM

URN No.: AH/2021-22/HL-03

0238696029 1806440000
Proposal no. _________________________________________ Intermediary Code: __________________________________
This is an application for insurance and issuance of this does not amount to acceptance of proposal by us. Commencement of risk under
this proposal is subject to acceptance of the risk by us and receipt of premium.
The information declared by you in this form is the basis for issuance of the policy. Please answer all questions carefully. Any incomplete,
incorrect or partially correct answers may lead to rejection of the proposal and also might lead to cancelation of policy.
Please fill-up this form in CAPITAL LETTERS
1. PROPOSER’S DETAILS

Name (Mr/Mrs/Ms/Dr):
Ms S H U B H I M A H E S H W A R I

Date of Birth: D3 D1 1
M 0
M 1Y 9Y 9Y 7
Y Gender: Male ✔ Female Others

Mobile: 9 4 2 5 4 2 8 4 8 3 Unique Govt ID No.:

Annual Income (in ` Lakhs): Upto 3 ✔ 3-6 6-10 10-15 15-20 20-25 >25

E-Mail ID: A E A G A R 8 @ G M A I L . C O M

Address^: M A K A N N O . 4 5 / 1 W A R D N O 2 0

Landmark: S A D A R B A Z A R

Area: C H H A V N I

City/Town: S H A J A P U R Pin Code: 4 6 5 4 4 1

District: S H A J A P U R State: M . P

PAN Card: C X I P M 7 7 3 7 F

(Mandatory in case of premium >`1 Lakh)

(In case proposer is not an individual entity then details of the entity to be filled, PAN is mandatory for such cases)
^ : Important Note:
• Here ‘Address’ implies the place where the person ordinarily resides. In case of lives to be insured reside at multiple addresses, then
address of the person residing in the highest zone to be provided.
Zone definitions (here Zone A is highest followed by Zone B and Zone C respectively):
Zone A: Mumbai including MMR/ Thane, Delhi NCR/Faridabad/Ghaziabad, Ahmedabad, Surat and Baroda
Zone B: Hyderabad, Bengaluru, Kolkata, Indore, Chennai, Chandigarh/ Mohali/ Punchkula/Zirakpur, Pune/Pimpri Chinchwad and Rajkot
Zone C: Rest of India
• Declared ‘Address’ will form the basis for the calculation of the premium. Mid-term zone change is subject to company guidelines/policy
• ‘Address’ is a material fact for calculation of the premium. Any misrepresentation or misdescription of the same by the policyholder may
lead to termination of the policy as per policy terms and conditions and accordingly all premium paid thereon shall be forfeited to the Company.

Tata Group Employee Tata Group Employee ID:

2. PLAN DETAILS
Proposed Policy Period: D
0 D
8 M1 1
M 2
Y 0Y 2Y 3Y To D
0 D7 M1 1
M 2
Y 0
Y 2Y 4Y
Policy Tenure: ✔ 1 Year 2 Years (5% premium discount) 3 Years (10% premium discount)

Sum insured type: Floater ✔ Individual

Room Category: ✔ All room categories covered Shared

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
Accidental Death Benefit* Yes
• Riders shall be opted by all the eligible members. There cannot be selection between the eligible members for choosing riders.
• Dependent Children will not be covered under Personal Accident Benefit.

3. DETAILS OF THE PERSON(S) TO BE INSURED

Sr Name of the Gender Relationship Date of Birth Height Weight Sum

M/F Insured#
No. Insured Person Others with Proposer* DD|MM|YYYY cms kgs

1 SHUBHI MAHESHWARI Female SELF 3 1 / 1 0 / 1 9 9 7 158 55 1,000,000

2 Male

3 Male

4 Male

5 Male

6 Male

7 Male

*Allowed relations (Spouse, children and dependent parents/parents in law)

Options available (3, 4, 5, 7.5, 10, 15, 20 Lakhs); Same Sum Insured for all members in floater option
#

4. NOMINEE DETAILS
In the event of the death of the Proposer any payment due under the Policy shall become payable to the nominee in accordance with the
Policy terms and conditions.

Nominee Name Date of Birth* Relationship Address of the Nominee

ANJU MAHESHWARI 1 5 / 0 3 / 1 9 7 3 MOTHER SAME AS PROPOSER

*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:

Appointee Name Relationship Address of the Appointee

5. EXISTING/PREVIOUS INSURER DETAILS

Is the proposer or any of the persons proposed, already Insured under a health plan with Tata AIG General Insurance Company Ltd. or any
0238692028
other insurer or is a proposal pending for Policy issuance? If yes, please indicate the Policy/Application number(s): ___________________________

Since when continuously insured: D

0 D8 M1 1
M 2
Y 0Y 2Y 0Y
Do you want Us to consider these details for portability*? Yes ✔ No

*In case of portability, please fill up IRDAI portability form. Please note that continuity of benefits shall NOT be considered if the details are not
provided. You need to approach at least 45 days prior to your expiry date to avoid any break in coverage. Please submit all previous year insurance
policy copies.

Period of Insurance Claims lodged during

Name of Sum Insured
the preceding year
Policy No Insured Insurer & Cumulative
From To along with
Person bonus / (`)
DD/MM/YYYY DD/MM/YYYY the diagnosis

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
6. MEDICAL AND LIFESTYLE DETAILS
A. Medical History:
Please answer the below mentioned questions individually in Yes(Y)/No (N):
You must answer the questions truthfully. Not doing so would lead to termination of your policy.

Insured Person
Please answer each of the following questions individually for each
1 2 3 4 5 6 7
Insured Person by ticking the relevant box.
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or hospitalized for or have been
recommended to take investigations / medication / surgery or undergone a surgery for the following medical conditions?

✔ Chest Pain / Heart Disease No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Arthritis No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ COPD No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Kidney Failure, Dialysis No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Liver Cirrhosis/Hepatitis B or C No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Cancer No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ HIV/AIDs/ No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Stroke, Epilepsy, Paralysis No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Psychiatric, Mental Illness or disorder No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Ulcerative Colitis/Crohn’s disease No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ Auto-immune diseases No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

✔ STDs No Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Any other illness/disease/injury/disability in the past other than
No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
for childbirth, flu or for minor injuries that have completely healed?
Are you or any persons proposed on regular medication
(including any Ayurvedic treatment) or awaiting any No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
procedure/treatment?

Have you ever been diagnosed with any of these medical

conditions with or without any follow-up tests/medications? –
No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Elevated Blood Sugar/ Diabetes/ Elevated Blood Pressure/
Hypertension/High Cholesterol/ Hypothyroidism

Is any of the insured pregnant currently? If yes, please mention

expected date of delivery (EDD). Any history of pregnancy related No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
complications?
EDD: DD/MM/YYYY No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Has any application for life, Health or critical illness insurance ever
been declined, postponed, loaded or been made subject to any No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
special conditions by any insurance company?

Has any health or life insurance policy ever been terminated in

No Y/N Y/N Y/N Y/N Y/N Y/N Y/N
the past?

B. Detailed information in case any of the questions in section 6 (A) is ticked ‘Yes’.
(Please send us medical documents along with this application form.)

Name of Disease
Insured Name Operative status Type of surgery Treatment status Complication(s)
(surgical)

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
 Name of Disease
Insured Name Operative status Type of surgery Treatment status Complication(s)
(surgical)

Name of Disease Mode of

Insured Name Date of diagnosis Medication history Progress Complication(s)
(medical) medication

Insured Name Remarks

C. Lifestyle Information
Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes ✔ No
If yes please indicate the name and quantity per day.

Insured Person

1 2 3 4 5 6 7

Alcohol (in ml)

• Per day
• Per week Quantity + Frequency
• Per month +Duration
• Occasionally
Smoking (No of Cigarettes or Bidis)
• Per day
• Per week Quantity + Frequency
• Per month +Duration
• Occasionally
Pan Masala/Tobacco (in gms)
• Per day
• Per week Quantity + Frequency
• Per month +Duration
• Occasionally

Others habit forming substances/addictive

(Quantity consumed)
• Per day
• Per week
• Per month
• Occasionally

7. PAYMENT DETAILS
Name of the Premium Payer: S H U B H I M A H E S H W A R I
(if different from proposer)
Relationship with the proposer: S E L F
(if different from proposer)

Premium Amount (in `) 3 0 0 3 3

Instrument type: Cash Cheque Debit Card Credit Card ✔ Others

Please make a Crossed Cheque/DD/Pay Order in favour of ‘Tata AIG General Insurance Company Limited’ only.

Sources of funds: ✔ Salary Business Other

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
AML guidelines:

1. I/we hereby confirm that all premiums paid / payable in future will be from bonafide sources and not paid out of proceeds of crime and
that such premiums are not disproportionate to my/our income. I / we understand that the Company has the right to call for documents to
establish sources of funds and to cancel the insurance policy in case I / we are found guilty by any competent court of law under any of the
statutes, directly or indirectly governing the prevention of money laundering law in India.

2. I/we are not Politically Exposed Persons * nor are their close relatives. I / we shall keep the company informed if we subsequently become
a Politically Exposed Person.

“Politically Exposed Persons” shall have the meaning assigned to it under sub clause (xii) of 3(b) of Chapter I of Master Direction – Know Your
Customer (KYC) Direction, 2016 issued by Reserve Bank of India (RBI), as amended from time to time.

• Nationality: ✔ Indian Non-Indian If Non-Indian, please specify Country: _____________________________________________

Type of Organization making the payment (Pls tick)

✔ Limited company Government organization Non-Governmental Organization (NGO)

Society Trust Partnership

International Organization Cooperatives Section 25 Company

2 1 / 1 1 / 2 0 2 3
Signature of Proposer: ________________________________________ Date: _______________________________

8. BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)

As per Regulatory requirements, we can effect payment of refund / claims only through Electronic Clearing System (ECS) / National Electronics
Funds Transfer (NEFT) / Real Time Gross Settlement (RTGS) / Interbank Mobile Payment Service (IMPS)

For this purpose, please submit the following details of the proposer’s bank account.

Name of the account holder:

Name of the bank:

Branch Bank:

Account no.:

Bank IFSC code:

Account Type: SB Account Current Account Others (please specify)

9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

✔ I 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 I am authorized to propose on
behalf of these other persons.

✔ 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 insurer and that the policy will come into force only after full payment of the premium chargeable.
✔ I further declare that I 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended
on the person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental
health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the
person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

✔ I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the
sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

Signature of the Proposer: _____________________________________ 2 1 / 1 1 / 2 0 2 3

Date: ________________________________

GoGreen: I would like to protect my environment and would like to help save paper by authorizing Tata AIG General Insurance Company
Limited to send all my policy and service related communication to the email id as mentioned in this application form. For detailed
terms, conditions, exclusions and policy wordings please refer our website ([Link])

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
10. DECLARATION/VERNACULAR DECLARATION

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have
understood these and confirm to abide by the policy terms & conditions.

Signature of the Proposer: _____________________________________________

Name & Signature of agent/intermediary with Code: ___________________________________________

Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print)

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to
the proposer who has understood and confirmed the same.

Signature/Thumb impression of the Proposer: _________________________________________

Name & Signature of agent/intermediary: ______________________________________________

11. AGENT DECLARATION

ABHINN JAIN
I,_________________________________________________________________ (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the
Corporate Agent/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 herein 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.

License No.(Intermediary/Corporate Agent/Broker/Relationship Officer): 1 8 0 6 4 4 0 0 0 0

Name of the specified Person and code: A B H I N N J A I N

INDORE
Place:______________________________

2 1 / 1 1 / 2 0 2 3
Date: _____________________________ Signature of Agent: __________________________________________

12. SECTION 41 OF INSURANCE ACT 1938 (PROHIBITION OF REBATES)

1. 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 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 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.

2. Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to
ten lakh rupees.

13. FOR OFFICE USE ONLY

Tata AIG Office Code: ______________________________________ Intermediary Code and Name: ______________________________________

Branch Receipt Date: ______________________________________ Channel Type: _______________________________________________________

Business Type: Urban Rural Social Customer ID: ________________________________________________________

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223
 ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)
Proposal Number: _____________________________________ Date: ______________________

Name of the Proposer _________________________________________________________________________________________________

We acknowledge with thanks the receipt of your proposal for Tata AIG MediCare and amount by cash cheque Demand Draft
others ________________________________ of amount of ` _______________________. Neither the submission to us of a completed proposal for
insurance nor any payment towards this application 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 proposal is not accepted by us or you do not accept the terms of counter offer or premium is not received by us in full
and in time, or non-fulfillments of Pre-Policy Checkup and/or additional information requested by us. We shall have no liability to make any
payment under the Policy if proposal is under-process & claim arises in the interim period before the decision on the proposal is given by us.
In case of counter offer you need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of such counter
offer letter. In case, You neither accept the counter offer nor revert to Us within 15 days, we shall cancel application and refund the amount
paid against this proposal without interest subject to deduction of the Pre Policy Check up charges, as applicable. If we do not accept the
proposal, we will inform you and refund any payment received from you without interest within next 10 days subject to deduction of the
Pre-Policy Check up charges, as applicable.
Tata AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) | E-mail: customersupport@[Link]
Website: [Link] | IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425 | UIN: TATHLIP23118V032223