APPLICATION FOR GROUP CREDIT PROTECTION PLUS

Master Policy Holder Name:

Master Policy No. Scheme name

Bajaj Allianz Life Insurance Company Limited, Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006.

Agent’s Details (For office use only)

Application No. Rural Banks MFI Corporate Agents Corporate Division NBPSU Co-operative Banks
Others Not to be filled Broker NBFC Web Sales BFL Scheduled Commercial Bank
Bank Ref. Code Not to be filled STM/FSC/ICName Not to be filled Branch
Receipt No. Not to be filled STM/FSC/ICCode Not to be filled Sector Urban Rural
1.Personal Details To be Filled by Member
Title Mr./Mrs./Ms./Dr.
Annual Income
Name First

Middle
Occupation

Last Exact Designation

Date of Birth D D M M Y Y Y Y Sex Male Female Building
C Door No.
Name
Nationality U
R
Age R Plot No./
E
N Steet Name
Age Proof Birth Certificate SSC Certificate Driving License
T Landmark/
Passport PAN Other Area
M Place
Preferred Language A
I City/District
I am a New Customer / Existing Customer L
I
Nominee Details (Under Section 39 of Insurance Act 1938) N State Pin Code
G Area Code Country Code Tel. No.
Name & Surname Nominee 1 Nominee 2 Nominee 3
A Tel.
Place of Birth D
D Country Code Mobile No.
Date of Birth R
E Mobile
Relationship to Member S
S E-mail
% Share of Nomination
If the Nominee is minor, an appointee who is a major shall sign the Application form below and shall
Appointee details (If nominee is a minor) identify the relationship with the Nominee. Relationship to the nominee
I accept the appointment herein made
Name & Surname Place of Birth Date of Birth Relationship to Member Signature Place

Collection Details
Coverage Information
GDC Cheque/DD Cash ECS Direct Debt
Premium (in `) Premium Paying Term
Bank Details (Not to be filled)
Date of deposit of Premium D D M M Y Y Y Y MICR Code
Premium Type Single Regular Membership Term IFSC Code
Premium Frequency (In case of Regular) Yearly Half Yearly A/C No.
Sum Assured Quarterly Monthly A/C Type
Cheque/DD No.
1. Primary Borrower share of liability in the loan______________%
Cheque/DD Date D D M M Y Y Y Y
2. Co-borrower share of liability in the loan______________% IT Assesse Yes No Pan No.
2. Accidental Permanent
1. Accelerated Critical Illness Yes No Yes No
Total Disability Benefit cover
To be filled by Master Policy Holder
MPH Branch Name Not to be filled Loan Account Number
Period of Loan / Remaining Loan Period Years Loan Amount / Ourstanding Balance (inclusive of premium if any) `

Rate of Interest % Date of Loan Disbursement Cover Tyoe - Level Reducing

Type of Loan: Construction equipment Commercial vehicle Gold Two Wheeler Secured Business Unsecured Business
Affordable Housing Housing Loan against property Personal Loan Car Loan Education Loan Other

Moratorium Moratorium Period in years (If ticked Yes) Premium Finance - Yes No
Simplified Medical Questionnaire (SMQ) Proposed Insured
Occupation: Salaried business Self-employed Retired Student Housewife Annual Income:
Nationality: Resident Indian NRI PIO Foreign National
a) Height (in cms)
b) Weight (in Kgs)
c) Has there been any variation in weight of more than 5 kg in the past 6 months (other than weight loss programme)? Yes No
1) Do you have any form of physical deformity, disability, accident history, injury, fractures, congenital diseases, external or
internal body defect which may or may not restrict your day today activities? Yes No
 2) Do you suffer from or have you suffered from or received consultation or investigation or treatment for or are you
Yes No
currently receiving treatment for or awaiting medical or surgical treatment for:
a) High Blood Pressure, cholesterol, Chest pain/discomfort, Heart Attack, irregular or fast heart rate or any other disorder of Yes No
heart or blood vessel, Stroke, Epilepsy, Paralysis in any form, or any other Cerebrovascular Disease;
b) Diabetes, sugar in urine, thyroid disease or any other Endocrinal Disease, or Kidney, prostate or genitourinary disease like blood or albumin in urine, Yes No
sexually transmitted or venereal diseases, etc.;
c) Any form of hepatitis, jaundice or liver Disease or disorders of eye/ear/nose/throat (excluding common cold) Yes No
d) Any lung or respiratory disease (e.g. Asthma, bronchitis, Tuberculosis, COPD, persistent cough, etc.). Yes No
e) Anaemia or any Blood Disorders, gastric or duodenal ulcers, colitis, chronic diarrhoea or other Gastro-Intestinal Diseases, or any other disorder of the Yes No
bones, spine or muscle like rheumatism, arthritis, gout, etc.:
f) Any Cancer or Cancerous growth, tumours, chemotherapy or radiotherapy of any kind; Yes No
g) Anxiety, depression or other Mental or Psychiatric condition, any Genetic Disease or chronic headache, multiple sclerosis, any disease related to central Yes No
nervous system (disease related to brain, spinal cord) or any autoimmune disorder;
h) HIV / AIDS or AIDS related compiications. Yes No
i) Do you have any habits e.g. smoking/ tobacco chewing, alcohol. narcotics etc. or were you advised to abstain from the same due to mecical reasons ?(if Yes No
yes, please fill up below details)

If yes Consumed as, Cigar Cigarette Beedi Gutka Frequency / Day, Nil 0-5 units 6-10 units >10 units Duration (in Years):

Alcohol: Yes No Quantity Beer (Bottles) Wine (Glasses) Hard Liquor (Pegs) Frequency: Nil Occasional 1-2 3-7 Above 7 Narcotics: Yes No
j) Have you ever undergone or have been advised to undergo any major surgical procedure or medical treatment for any conditions/illness/disorder not Yes No
listed above or any complaints or symptoms for which a physicain has not been consulted?
k) In the last five years, have you been continuously hospitalized for more than 7 days (other than fractures) or undergone any investigations (including Yes No
basic radiological and blood tests) other than normal Health Check-ups and Insurance Medicals, or have had adverse result for any blood tests, X-Rays,
ECG, Stress Test, Biopsies, CT Scan, MRI, Ultra-sonography or 2D / 3D Echo etc.
Yes No
3) Does any member of your immediate family e.g. parents, brothers, sisters, suffered from high blood pressure, diabetes, heart disease, stroke, cancer, kidney
failure, or any other chronic or hereditary conditions before the age of 60 yrs.
4) a. Do you have existing/proposed insurance cover from Bajaj Life Insurance or other life insurance companies? Yes No
b. Did any of your proposal and / or policy for life, health, accident or critical illness or any other riders, including simultaneous / renewals / revivals
Yes No
therefore, declined, deferred, withdrawn or accepted at extra premium or reduced cover or offered any special terms by any insurance company.
c. Have you ever received or do you now receive any benefits under health/disability/critical insurance cover? Yes No
5) Do you engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature (e.g. occupation - chemical factory, mines, Yes No
explosives; aviation other than fare paying passengers, diving, mountaineering, any form of motor racing, etc.)
6) For females lives only:
a) Are you pregnant? If “Yes” , please state the expected date of delivery: Yes No
b) Have you ever had any disorder of female organs or any abnormality of complications during pregnancy like eclampsia, gestational diabetes, recurrent Yes No
miscarriage, etc?. If Yes Give details.
7. Currently or in past did you ever suffer from disorder of heart/ blood pressure/ stroke/ asthma/ lung/ cancer/ HIV/ brain/ diabetes/ liver/ digestive tract/
urinary/ kidney/depression /mental health / epilepsy /blood /any disability.
8. Did you ever have symptoms or have been absent from work for any illness/ injury/ disability presisting for more than 7 days in last 3 years.
9. Currently or in past 12 months, have you ever tested positive for covid-19/ novel coronavirus or underwent any Hospitalization for Covid 19?
10. The health Declaration shall form the basis of your enrolment Any known misstatement, misrepresentation and /or omission of material importance may
void the coverage under this policy.

Please provide complete details if any of the above question is answered in affirmation:

Covid-19 Questions
Currently or in the last 3 months have you or your family members been tested positive for Covid 19 / Have been self isolated with symptoms medical advice Yes No
advised to undergo, repeat or awaiting Covid 19 test/ Do you currently or in the past 1 month have symptoms like persistent cough, breathlessness, fever, raised
temperature or flu like symptoms / Been in contact with an individual suspected or quarantined or confirmed to have COVID-19 or Sars cov-2/ or does your or
immediate family members occupation require you/them to come n close contact with COVID-19 patients or with coronavirus contaminated material?”

Please provide complete details if above question is answered Yes:

Have you or your immediate family members travelled overseas in the last 45 days OR plan to travel outside India during the next 6 months ? Yes No
Please provide complete details in the declaration given below, if above question is answered Yes:

Country City Date Arrived/Arrival Date Departed OR intended duration

 Declaration (Please do not sign on blank proposal form)
I here by declare that the information provided in the above questionnaire is true to the best of my knowledge. I confirm that the answers I have given are, to the best of my knowledge, true, and that I
have not withheld any material information that may influence the assessment or acceptance of this application. I agree that this form will constitute part of my application for insurance (s) and that
failure to disclose any material fact know to me may invalidate my insurance (s).
I/We fully understand that any personal information collected or held by the Bajaj Allianz Life Insurace Company Limited (”Company”)(whether contained in this application or otherwise obtained) may
be held, used and disclosed by the Company to reinsurance companines, claims investigation agencies, credit/claim/fraud bureaus or service providers or repositories and releant industry
associations/federations for the purpsoe of underwriting or claims processing or gor any analysis.
“I/We am/are aware that the policy shall be governed by the Terms & Conditions of the policy issued by BAJAJ ALLIANZ LIFE INSURANCE CO. LTD. Pursuant to the propsal for insurance made by us. I/We
have independently verified the information before making my/our decision.
I/We am/are aware that the GCPP policy thken by me/us, is issued and underwritten by BAJAJ ALLIANZ LIFE INSURANCE CO. LTD., and that all claims will be settled BAJAJ ALLIANZ LIFE INSURANCE CO.
LTD., as per the terms and conditions of the policy.
I/We hereby confirm that I/We have agreed to subscribe to the policy purely on a voluntary basis after taking my/our independent professional advise and that__________________________shall not
be liable for any liability for loss or damage of whatsoever nature, which may be attributable to payment of claims under the policy of Insurance.”
The above declatration and other details are true to best of my knowledge. I have been explained the rules of the scheme and have understood them.

Date: D D M M Y Y Signature of Primary member: Place

Place
Witness signature Place Date: D D M M Y Y

Vernacular Declaration / Specimen Signature (Please do not sign on blank proposal form)
If the signature herein is in vernacular then the proposed insured/proposer should declare below in his /her own handwriting ( in the same language in which the Application is signed) that the
replies were after and properly understanding the question and declarations mentioned above. The contents of the form and documents have been fully explained to me and that I have fully
understood the significance of the proposed contract

Signature or Thumb Impression of Life Assured Date D D M M Y Y Y Y

Name & Address of the witness

Signature of the witness Date D D M M Y Y

I hereby declare that the contents of the Application form including the declarations have been explained to the proposer and replies have been recorded as per the information provided by the
Counter Member and all the answers have been read out and fully understood by and confirmed by the Counter Member
Name & Address of person filling up the Application form
Signature of person filling up the Application form Master Policy Holder Signature and Seal

Date D D M M Y Y
Date D D M M Y Y
I have understood the content of the proposal form as explained to me in _______language by the person, Mr./Ms___________, filling in the proposal form and after the same, I am affixing my
signature/thumb - impression.
Vernacular Declaration in Regional Language_________________ Signature/thumb impression of the Life Assured___________________________

Declaration for Settlement of Claim Amount in Favour of Master Policy Holder who is a Regulated Entity.
In the event of any eventuality giving rise to a claim under the group insurance scheme, the claim proceeds should be utilized to liquidate the outstanding loan availed by me. I authorize MPH to
receive the outstanding loan amount of the claim proceeds, from Bajaj Allianz Life Insurance Company Limited, which is authorized to make payment directly to and in the name of the MPH to
the extent of outstanding loan amount left, if any, may be paid by BALIC to me or my nominee/beneficiary, as the cas may be. Bajaj Allianz Life Insurance Company Limited shall be discharged to
the extent of amont paid to the MPH towards outstanding loan amount. It shall be solely my responsibility to bring to the notice of BALIC, in the event I intend to make a change in my declaration
as made herein above. This declaration is applicable when the MPH is a regulated entity or as specified by IRDAI from time to time. In the event refund of insurance premium, if any on account of
my cover being cancelled either by way “Free Look cancellation or cancellation form inception” and / or in the event of any eventuality giving right to claim under the group insurance scheme, I
hereby authorize Bajaj Allianz Life Insurance Co Ltd (The Company) to refund the insurance premium to Master Policyholder from whom I had availed loan.

Signature of the Life Assured MPH Seal

Acknowledgment
Customer Name: __________________________________________________________________ Loan Application No:_________________________________ APP NO: ________________________
This is to confirm the receipt of your application for Bajaj Allianz Life Croup Credit Protection Plus for which you have agreed to authorize Axis Bank Ltd. (”Master Policyholder”) to remit the premium to
Bajaj Allianz Life Insurance Company Limited (BALIC).

(Signature of Axis Bank Representative)

Please note that submission of your application does not mean automatic commencemet of life insurance coverage. Your proposal may require underwriting or you may be required to undergo medical
examinations if the need aries. Life insurace cover shall xommence only after satisfactory completion of medical and/ or financial underwriting conducted by BALIC and subsequent written confirmation
through Certificate of Insurance conveying the commencement of life insurance coverage.
 Additional Information (If Applicable)

Sr. No Questions Response

1 Name of Entiy
2 Relation of Entity with Insured Person
3 Insured person share % to Entity
4 Address of the entity : ______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________ Pin Code : ___________________

Sr. No Questions Yes No Additional Information to be added PF

1 Is the Life Insurance cover applied on Main Applicant?
2 Is the Life insurance cover applied on Co - Applicant or Co Borrower?
2.a If Yes, then please provide the shareholding of Co borrower in loan amount along with supporting documents
3 Is the Loan taken on Individual?
4 Is the Loan taken on Company Name?
4.a If Yes, then please provide the shareholding pattern of Company along with supporting documents

Signature of the Life Assured MPH Seal