Apollo Munich HEALTH PLAN

Transcription

1 Apollo Munich HEALTH PLAN Points to Remember Apollo Munich Health Plan tailor made exclusively for you to offer them coverages like never before. The Plan is designed to answer all your health insurance requirements and allows you to choose the plan option suited to your requirement. 1 Maximum Age: The maximum entry age is 65 years. There is no maximum cover ceasing age in this policy. 2 Minimum Age: The minimum entry age is 91 days. Children between 91 days and 5 years can be insured if either parent is getting insured under this policy. 3 The cover will be valid for 1 or 2 year(s) as opted. An additional 7.5% discount is offered on the premium if you choose a 2 year policy. 4 An individual and/or his family members namely spouse, dependent children, dependent parents or parents-in-law are eligible for buying this cover on an individual or floater basis. 5 A maximum of 6 members can be added in a single policy, whether on individual or floater basis. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law. 6 The insured and his family cannot select sum insured across variants in a single policy/application.

2 Features and Benefits: Basic Sum Insured per Insured Person per Policy Year (Rs. in Lakh) Apollo Munich Health Plan - Individual Silver Gold Platinum 2.00, 3.00, 4.00, , a) In-patient Treatment Covered Covered Covered 15.00, 20.00, 25.00, b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days 1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days 1d) Day Care Procedures Covered Covered Covered 1e) Domiciliary Treatment Covered Covered Covered 1f) Organ Donor Covered Covered Covered 1g) Daily cash for choosing shared accommodation Rs.500 per day maximum upto Rs.3,000 Rs.800 per day maximum upto Rs.4,800 1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization 2) Restore Benefit 3) Multiplier Benefit Not Covered 4) e-opinion in respect to a critical illness 5) Health Checkup Benefit Not Covered 6) Outpatient Benefit 7) Hospital Daily Cash 8) Maternity benefit Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. Yes Yes Yes Rs.5,000 per individual post waiting period of 2 years Rs. 500 per day up to a maximum of 30 days on individual basis Not covered 1% of sum insured subject to a maximum of Rs.5,000 per insured person at the end of every policy year. Rs.10,000 per individual post waiting period of 2 years Rs. 1,000 per day up to a maximum of 30 days on individual basis Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit of Rs.4,500) [Waiting Period of 3 years] Rs.800 per day maximum upto Rs.4,800 Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. For SI of 15 lacs : Upto 1% of the Sum insured subject to a maximum of Rs 7,500 per insured person at the end of every policy year. For SI of 20 lacs & above : Upto 1% of the Sum insured subject to a maximum of Rs 10,000 per insured person at the end of every policy year. Rs.25,000 per individual post waiting period of 2 years Rs 2,000 per day upto a maximum of 90 days on individual basis Not covered 9) New Born Baby cover Not covered Covered Not covered Basic Sum Insured per family per Policy Year (Rs. in Lakh) Apollo Munich Health Plan Family Floater Silver Gold Platinum 2.00, 3.00, 4.00, , a) In-patient Treatment Covered Covered Covered 15.00, 20.00, 25.00, b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days 1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days 1d) Day Care Procedures Covered Covered Covered 1e) Domiciliary Treatment Covered Covered Covered 1f) Organ Donor Covered Covered Covered 1g) Daily cash for choosing shared accommodation Rs.500 per day maximum upto Rs.3,000 Rs.800 per day maximum upto Rs.4,800 1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization Rs.800 per day maximum upto Rs.4,800 Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above

3 Apollo Munich Health Plan Family Floater Silver Gold Platinum 2) Restore Benefit Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. 3) Multiplier Benefit Not Covered 4) e-opinion in respect to a critical illness 5) Health Checkup Benefit Not Covered 6) Outpatient Benefit 7) Hospital Daily Cash 8) Maternity benefit Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. Yes Yes Yes Rs.5,000 per family post waiting period of 2 years Rs. 500 per day up to a maximum of 30 days on individual basis Not covered Upto 1% of sum insured per policy subject to a maximum of Rs.5,000 per insured person at the end of every policy year. Rs.10,000 per family post waiting period of 2 years Rs per day up to a maximum of 30 days on individual basis Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit of Rs.4,500) [Waiting Period of 3 years] Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. For SI of 15 lacs : Upto 1% of the Sum insured per policy subject to a maximum of Rs 7,500 per insured person at the end of every policy year. For SI of 20 lacs & above : Upto 1% of the Sum insured per policy subject to a maximum of Rs 10,000 per insured person at the end of every policy year. Rs.25,000 per family post waiting period of 2 years Rs 2000 per day upto a maximum of 90 days on individual basis Not covered 9) New Born Baby cover Not covered Covered Not covered Other Features Lifelong renewal: Renew your cover lifelong and stay covered forever. No sublimit or copay: Enjoy your health plan without sub limits and copays. Cashless transactions: Apollo Munich Health Plan enables you to get treated on a cashless basis across 4000 hospitals in over 800 cities. No geography based sub-limits: No matter where you buy your policy you can get treated in any city or hospital you like in the country with no additional copays or sub limits. No claim based loading: We will never load your renewal premium because you claimed or fell ill after taking our policy. Exclusions: Any treatment within 30 days of cover except any accidental injury Any pre existing diseases/conditions will be covered after a waiting period of 2 years in Platinum Plan option & 3 years in Silver and Gold Plan. 2 year exclusion for specific diseases like cataract, hernia,hysterectomy, joint replacement etc Expenses arising from HIV or AIDS and related diseases Quick turnaround time: You don t have to worry about pre-authorization, 90% of pre-authorization is done within 2 hours. Quick claim payment: When it comes to claim settlement, we re one of the fastest in the industry to honour every genuine claim. Easy upgrade: This health plan also comes with an easy upgrade option. You can upgrade your cover to the next slab at the time of your policy renewal. Tax benefits: You can avail tax benefits for the premium amount under Section 80 D of the Income Tax Act. (Tax benefits are subject to changes in tax) Abuse of intoxicant or hallucinogenic substance like drugs and alcohol. Hospitalization due to war or an act of war or due to nuclear, chemical or biological weapon and radiation of any kind. Non-allopathic treatment, congenital diseases, mental disorder, cosmetic surgery or weight control treatments. For complete exclusions please refer to the policy document Renewal Incentives: Multiplier Benefit: A Bonus of 50% of the basic sum insured for every claim free year will be offered accumulating up to 100%. In the event of a claim, the bonus shall be reduced by 50% of the basic sum insured at the time of renewal. However this reduction will not reduce the sum insured below the basic sum insured of the policy. This benefit is applicable to only Gold and Platinum plan. Portability: If you are insured under another Insurer`s health insurance policy, You can transfer to Apollo Munich with all your accrued benefits and due allowances for waiting periods etc to the extent of sum of previous sum insured and accrued cumulative bonus and it shall not apply to any other additional increased sum insured. Terms of Renewal: We offer life-long renewal regardless of your health status or previous claims made under your policy, unless the insured person or any one acting on behalf of an insured person has acted in an improper, dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the policy pose a moral hazard. Grace Period - Grace Period of 30 days for renewing the policy is provided under this policy. Any disease/condition contracted during the Grace Period will not be covered and will be treated as a Pre-existing condition. Maximum Age There is no maximum cover ceasing age in this policy.

4 Waiting Period - The waiting periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of the Apollo Munich Health Plan policy. Renewal premium are subject to change with prior approval from IRDAI. Any change in benefits or premium (other than due to change in age) will be done with the approval of the Insurance Regulatory and Development Authority of India and will be intimated at least 3 months in advance. In the likelihood of this policy being withdrawn in future, intimation will be sent to insured person about the same 3 months prior to expiry of the policy. Insured person will have the option to migrate to similar indemnity health insurance policy available with us at the time of renewal with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break as per portability guidelines issued by IRDAI. Discounts: Family discount of 5% if 2 family members are covered and 10% if 3 or more family members are covered under Apollo Munich Health Plan on Individual Sum Insured basis. Basic Sum Insured Enhancement Sum insured can be enhanced only at the time of renewal subject to no claim have been lodged/ paid under the policy. If the insured enhances the basic sum insured one grid up, no fresh medicals shall be required. In cases where the basic sum insured enhanced is more than one grid up, the case shall be subject to medicals. In case of enhancement in the basic sum insured waiting period will apply afresh in relation to the amount by which the basic sum insured has been enhanced. However the quantum of enhancement shall be at sole discretion of underwriting. Any insured person in the policy has the option to migrate to similar indemnity health insurance policy available with us at the time of renewal subject to underwriting with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break. Child dependent after attaining the age of 25 years will be offered coverage under separate individual policy with all continuity benefits. 7.5% discount on premium if insured person is paying premium of 2 years in advance as single premium. Free Look Period: You have a period of 15 days from policy receipt date to review your policy. If You have any objections to any of the terms and conditions, You have the option of cancelling the policy stating the reasons for cancellation and You shall be refunded the premium paid by You after adjusting the amounts spent on any medical check-up and stamp duty charges. You can cancel your policy only if You have not made any claims under the policy. All Your rights under this policy shall immediately stand extinguished on the free look cancellation of the policy. Free look provision is not applicable and available at the time of renewal of the policy. Termination (other than Free Look Period): The policyholder may terminate this policy at any time by giving us written notice or call 24 x 7 CitiPhone or post internet banking login, and the policy shall terminate when such written notice or call is received. If no claim has been made under the policy, then we will refund part of the premium paid after retaining premiums as applicable short period rates in accordance with the policy document. Tax Benefit: We may terminate this policy on grounds of misrepresentation, fraud, nondisclosure of material facts or noncooperation by the policyholder or any insured person or anyone acting on the policyholder s behalf or on behalf of an insured person upon 30 days notice by sending an endorsement to the policyholder s address shown in the schedule without refund of premium. The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act, subject to applicable tax laws. Disclaimer This is only a summary of the product features. The actual benefits available are as described in the policy, and will be subject to the policy terms, conditions and exclusions. This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. with its registered office at Apollo Hospitals Complex, Jubilee Hills, Hyderabad-33. For more details on risk factors, terms & conditions, Please read the policy terms and conditions carefully before concluding sales. All Insurance applications are subject to the Insurance Company`s underwriting and acceptance. Section 41 of Insurance Act 1938 as amended by Insurance Laws Amendment Act, 2015 (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 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 prospectuses or tables of the insurers. 2) Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees. Reach Us Customers can contact / get detailed process information for Post freelook cancellation/ termination/surrender/ and refund, Claims and Escalations / service queries Citicare@apollomunichinsurance.com; Log on to : Write to Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Call:

5 Tariff Sheet: Apollo Munich Health Plan Annual Individual Premium (Inclusive of goods & services tax) Silver Gold Platinum Age Group (Years) 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A > Annual Family Floater Premiums (Inclusive of goods & services tax) Silver Gold Platinum Age Group (Years) 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C > Age Group (Years) 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C > Age Group (Years) 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C >

6 Age Group (Years) 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C ,181 18,271 21,200 23,115 35,722 39,674 54,031 57,282 60,350 71, ,510 18,804 21,814 23,780 37,243 41,371 56,378 59,774 62,980 74, ,368 22,246 26,028 28,499 45,111 50,423 66,853 71,222 75,349 90, ,936 25,293 29,737 32,640 52,171 58,514 76,450 81,667 86, , ,046 29,125 34,384 37,820 61,385 69,057 89,078 95, , , ,097 35,441 42,067 46,396 76,744 86, , , , , ,896 43,955 52,436 57,977 97, , , , , , ,330 50,686 60,569 67, , , , , , , ,388 58,250 69,762 77, , , , , , ,606 >80 54,970 65,186 78,163 86, , , , , , ,785 Age Group (Years) 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C ,065 20,612 24,038 26,276 40,182 44,760 60,256 64,021 67,575 80, ,394 21,146 24,651 26,941 41,702 46,457 62,603 66,513 70,204 83, ,252 24,588 28,866 31,660 49,570 55,509 73,078 77,961 82,573 99, ,820 27,635 32,575 35,801 56,630 63,600 82,675 88,406 93, , ,930 31,467 37,222 40,981 65,844 74,143 95, , , , ,981 37,782 44,904 49,557 81,203 91, , , , , ,780 46,297 55,274 61, , , , , , , ,214 53,028 63,407 70, , , , , , , ,272 60,592 72,600 80, , , , , , ,597 >80 56,854 67,528 81,000 89, , , , , , ,776 Age Group (Years) 2A 2A 2A 2A 2A 2A 2A 2A 2A 2A > Age Group (Years) 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C >

7 Age Group (Years) 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C > Age Group (Years) 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C > Age Group (Years) 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C > The premium mentioned is annual premium. All premium are inclusive of applicable Goods and Services Tax A family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policy under individual sum insured plan

8 2 Year Premium 2 Year Individual Premium (Inclusive of goods & services tax) Silver Gold Platinum Age Group (Years) 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A > Year Family Floater Premiums (Inclusive of goods & services tax) Silver Gold Platinum Age Group (Years) 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C >

9 Age Group (Years) 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C > Age Group (Years) 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C > Age Group (Years) 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C

10 > Age Group (Years) 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C > Age Group (Years) 2A 2A 2A 2A 2A 2A 2A 2A 2A 2A >

11 Age Group (Years) 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C > Age Group (Years) 2A+2C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C > Age Group (Years) 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C

12 > Age Group (Years) 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C > All premium rates are inclusive of 2 year premium discount and applicable Goods and Services Tax A family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policy under individual sum insured plan Loading We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). The maximum risk loading applicable for an individual shall not exceed above 100% per diagnosis / medical condition and an overall risk loading of over 150% per person. These loadings are applied from commencement date of the policy including subsequent renewal(s) with us or on the receipt of the request of increase in sum insured (for the increased sum insured). Please Note. 1. Premium rates and policy terms and conditions are for standard healthy individuals. These may change post underwriting of proposal based on medical tests (where applicable) and information provided on the proposal form. Please visit our nearest branch to refer to our underwriting guidelines, if required. Premium rates are subject to change with prior approval from IRDAI. 2. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law. Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Corp. Office: 1st Floor, SCF -19, Sector - 14, Gurgaon , Haryana. Regd. Office: Apollo Hospitals Complex, Jubilee Hills, Hyderabad , Telangana. Tel: Fax: Toll Free: citicare@apollomunichinsurance.com Website: AMHI/MA/H/0002/0122/072014/P CT/AMHP/BR/V0.04/ Citibank is a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number CA0086. This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. Participation by the bank s customers in an insurance product is purely on a voluntary basis. For more details on terms and conditions please read sales brochure carefully before concluding a sale. Tax laws are subject to change IRDAI Reg. No.: CIN: U66030AP2006PLC UIN: IRDA/NL-HLT /AMHI/P-H/V.1/15/13-14 JSA/M/C16/343

13 Apollo Munich HEALTH PLAN Application Number. Specified Person Name Code Location This is an application for Insurance. Every Information this application seeks is important. Please read all questions and answer them carefully. You must provide complete and correct information. Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy even if it is issued. It is not obligatory for us to accept any risk or issue policy to anyone. Regulations mandate that the coverage can incept only after we have received the full amount of premium and have explicitly accepted the risk. We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). Please note that We will issue Policy only after getting Your consent in case of risk loading. We are under no obligation to accept any proposal for insurance. 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 under the Policy 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 is not realised, or non-fulfillments of Pre Policy Checkup and/or additional information requested by us. To be filled by the Bank Customer Segment: CPC Citigold Citibanking Suvidha Others ( please mention) To be filled by the Customer Please note all sections are mandatory (except for the sections marked*) 1. PROPOSER DETAILS Name: (Mr./Ms./Mrs.) First Name Middle Name Last Name Address Pin Code District/City State id Date of Birth D D M M Y Y Y Y STD Code Landline Mobile Annual Income Marital Status Nationality *Id Proof Type : PAN Passport Driving License Voter s Card If Other, please specify *Id Proof No. Please circle against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the listed titles below, please tick against all the applicable heads. Head of State or of Government / Senior Politician / Senior Government / Judicial / Military Officer / Senior Executive of State-Owned Corporation / Important Political Party Official 2. PLAN DETAILS Plan Name: Apollo Munich Health Plan - Silver Gold Platinum Type of Policy: Individual Floater Policy Period: 1 Year 2 Year 3. PROPOSED INSURED(S) DETAILS S.No Name of the Insured person Relationship to Policyholder Gender Date of Birth Height (cms) Weight (kgs) Note: The insured and his family cannot select sum insured across variants in a single policy/application Children aged between 91 days and 25 years can be covered. If the child age is between 91 days to 5 years, please confirm whether one of the parent is getting covered in the plan Yes No * Family Floater policy will have same Sum Insured for all members Sum insured* ( in Rs.) Total premium including goods & services tax Deduct 5% family discount if 2 member and 10% if 3 or more member are covered in case of individual plan. The discount may change if there is a change in the number of members covered in the policy at renewal. Total premium payable Premium ( in Rs.) 4. NOMINEE DETAILS In the event of the death of an Insured Person any payment due under the Policy shall become payable to the nominee in accordance with the policy terms and conditions. The nominee must be an immediate relative of the Proposer. The nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself. Nominee Name Relationship to Proposer *5. PHOTOGRAPHS Please paste the photographs in sequence [Insured 1, Insured 2, Insured 3, Insured 4, Insured 5 and Insured 6] as specified in section 3 of details of proposed to be insured Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h)

14 6. MEDICAL QUESTIONNAIRE (Medical & Life Style Information (Declaration)) Have you or any other member(s) proposed to be insured under this policy ever suffered from or are suffering from any of the following: Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Arthritis, disorders of the spinal cord or vertebral column for example slipped disc. Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Circulatory disorder, heart condition, paralysis of any kind, Haematological (blood) disorder Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Tumour or cancer of any kind, Diabetes, high blood pressure, allergies Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Disorders of the stomach / large or small intestine, hernia of any kind, haemorrhoids Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Nervous disorder, fainting episode, blackouts, fits, mental condition Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Respiratory disorder, urinary disorder, varicose veins Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Any diseases or injury requiring surgical or medical treatment Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Have you or any other member proposed to be insured under this policy sought medical advice in past 10 years or been advised or awaiting any treatment medical or surgical due to any of the diseases/conditions listed above or otherwise or attended follow up for any disease / condition / ailment/ injury / addiction (except Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N for infrequent common illness for example common cold, loose motions, cough and cold, headaches, acidity)? Does your or any of the person proposed under this policy s occupation or nature of job involve working in military or paramilitary forces, security forces, merchant navy or shipping, mines, electrical, aviation (flying), Oil or natural gas production or refining, explosive units or chemical industry or metal industry; working at Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N heights (above or underground/sea level); handling of heavy machinery or hazardous materials; driving of heavy motor vehicles or significant manual labor? Is any of the insured pregnant? If yes please mention the expected date of delivery D D M M Y Y Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N To be filled if any of the answers to above questions is answered as Yes Insured Person Name and details of Illness/ Medicine/Test/Surgery/Condition Diagnosis Date or Date of last consultation Details if inpatient/ outpatient was given To provide additional information for other insured member(s), please provide details in above format on an extra sheet duly signed. 7. PORTABILITY I want to avail portability benefit? Yes No (if yes, please fill the portability form and submit portability documents) 8. EXISTING/PREVIOUS INSURER DETAILS Policyholder Name Policy No./Application No. Insurer From Period of Insurance To D D M M Y Y D D M M Y Y Sum Insured (Rs.) Claims lodged during the preceding years 9. PREMIUM PAYMENT DETAILS Instrument (Credit Card,Bank Account) Instrument Number Instrument Date Name of Payor Bank Name IFSC Code Amount ( Rs.) In case Premium is more than Rs.50,000, please provide PAN details. NA NA Citibank Section 41 of Insurance Act 1938 as amended by Insurance Laws Amendment Act, 2015 (Prohibition of Rebates): 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 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 prospectuses or tables of the insurers. Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees. 10. EXCLUSIONS Following is an outline of the main exclusions below. Please refer policy wordings for detailed exclusions before purchasing this policy. Any illness/ disease/ injury pre-existing before the inception of the policy for the first 2/3 years, Non-allopathic treatment,, cosmetic aesthetic, dental treatment and obesity-related treatment, Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury, Medical expenses incurred during the first 30 days of inception of the policy, except those arising out of accidents, 2 years waiting period for the specified illnesses/ surgeries. This exclusion doesn t apply for subsequent renewals without a break, Congenital disease, genetic disorders, stem cell implantation, War, riot, strike, nuclear weapons induced hospitalisation, any hazardous or dangerous or adventurous activities, Psychiatric, mental or nervous disorders, Parkinson and Alzheimer s disease, measures primarily for diagnostic, X-ray or laboratory examinations which are not consistent with or incidental to the diagnosis and treatment, general debility or exhaustion, any treatment that is not of a reasonable cost, not medically necessary; drugs or treatments which are not supported by a prescription, crutches or any other external appliance and/or device used for diagnosis or treatment. 11. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS TO BE INSURED I/ We 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/We am/are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of insurance policy, is subject to the Board approved underwriting policy of the Insurance Company and that the policy will come into force only after full receipt of the premium chargeable. I/ We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/ proposer after the proposal has been submitted but before communication of the risk acceptance by the company. I/ We declare and consent to the company seeking medical 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 for insurance on the life to be assured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement. I/ We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/ or Regulatory Authority. I understand that the AMHI may terminate the policy immediately, on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by any Insured Person or anyone acting on policy holder s behalf or on behalf of an Insured Person upon 30 days notice by sending an endorsement to Insured Person s address shown in the Schedule without refund of premium. I confirm that I have read the brochure and understood all the terms and conditions, coverage s, and exclusion (related to: pre-existing diseases, waiting period and exclusion) and I accept them. I understand that Citibank N.A. will earn 15% as commission on this policy in their capacity as the licensed Corporate Agent of Apollo Munich Heath Insurance Company Limited. Signature of Proposer: Date: Time: Place: For detailed terms and conditions, please refer insurance policy document. 12. VERNACULAR DECLARATION Certification in case the proposer has signed in vernacular (to be witnessed by someone other than agent/employee of the company): Name of Proposer: 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. Signature of Proposer: Signature of the witness: Date: Place Name of the witness: Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Corp. Office: 1st Floor, SCF -19, Sector - 14, Gurgaon , Haryana. Regd. Office: Apollo Hospitals Complex, Jubilee Hills, Hyderabad , Telangana. Tel: Fax: Toll Free: citicare@apollomunichinsurance.com Website: Citibank is a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number CA0086. This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. Participation by the bank s customers in an insurance product is purely on a voluntary basis. For more details on terms and conditions please read sales brochure carefully before concluding a sale. Tax laws are subject to change IRDAI Reg. No.: CIN: U66030AP2006PLC UIN: IRDA/NL-HLT /AMHI/P-H/V.1/15/13-14 AMHI/PR/H/0034/0122/072014/P