Apollo Munich GROUP PERSONAL ACCIDENT INSURANCE A Platinum Plan for Citibank Customers Benefits You cannot predict accidents 1 Accidental Death [AD] - A lump sum payment would be made in the event of death due to an accident. 2 Transportation of Mortal Remains - Expenses incurred on transporting the mortal remains of the insured person from the place of the accident or the hospital to his residence or hospital or to a cremation or burial ground. 3 Cremation Ceremony- A lump sum payment would be made towards the costs of the cremation or burial of the insured person. 4 Permanent Total Disablement [PTD] - A lump sum payment would be made, as per the scale provided in the policy, in the event of permanent total disability due to an accident. 5 Permanent Partial Disablement [PPD] - A lump sum payment would be made, as per the scale provided in the policy, in the event of permanent partial disability due to an accident. 6 Emergency Ambulance Cover - Expenses incurred on an ambulance used to transfer the insured person to the nearest hospital by the shortest route following an emergency caused due to an accident. 7 Education Fund - If a claim under AD or PTD is accepted for an insured person, we will pay 50% of education fund sum insured per dependent child (up to maximum of two children), provided that such dependent child is pursuing an educational course as a full time student in an educational institution. 8 Accident In-patient Hospitalisation - If any insured person suffers an accident during the policy period that requires hospitalisation, we will reimburse the medical expenses incurred for in-patient treatment in a hospital. 9 Broken Bones - A lump sum payment would be made, as per the scale provided in the policy, in the event of fracture of bone due to an accident. and some unfortunate accidental occurrence might bring a huge financial burden to you and your family. Although you cannot guard against all uncertainties of life, you can always take steps towards securing your family s future and providing financial stability to recover from your financial loss. A personal accident insurance ensures the financial stability for you and your family in the event of an accident.
Benefit Grid Benefits Plan Accidental Death [AD] Sum Insured Options (Rupee in Lakhs) 5, 10, 15, 25, 30, 50, 75,100, 200, 300,400,500 Transportation of Mortal Remains Cremation Ceremony Permanent Total Disablement [PTD] Permanent Partial Disablement [PPD] 2% of AD Sum Insured, maximum upto Rs.10,000 2% of AD Sum Insured, maximum upto Rs.10,000 Upto AD Sum Insured (as per table of benefits) Upto AD Sum Insured (as per table of benefits) Emergency Ambulance Cover Maximum upto Rs 2,000 Education Fund 10 % of AD Sum Insured; maximum upto Rs 20,000 Accidental Inpatient Hospitalisation Maximum upto Rs 1,00,000 Broken Bones 20 % of AD Sum Insured; maximum upto Rs 1,00,000 Eligibility a) This policy covers persons in the age group of 91 days to 69 years. The maximum entry age is 69 years. b) There is no maximum cover ceasing age in this policy. c) The policy will be issued for a 1 year period. d) This policy can be issued to an individual and/or a family on individual basis. e) The family includes spouse, dependent children and dependent parents. f) The Citibank customer must be insured in the policy. For account holder less than 18 years of age, either parent must be covered in the policy. g) A child getting insured as a dependent child (below 21years) can be covered only if either parent is covered under the policy. Terms of Renewal We offer life-long renewal. Grace Period of 30 days for renewing the policy is provided under this policy. In the likelihood of this policy being withdrawn in future, intimation Geography This policy compensates for injuries sustained, occurred anywhere in the world. The benefit in respect of accident in-patient hospitalization shall Exclusions Any Pre-existing Condition or any complication arising from the same. Intentional self injury, suicide or attempted suicide, while sane or insane. Any psychiatric or mental disorders. AIDS (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus), venereal disease, sexually transmitted disease or illness. Any Insured Person s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Arising or resulting from the insured person(s) committing any breach of law with criminal intent. The abuse or the consequences of the abuse of intoxicants or 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 a similar personal accident insurance policy available with us at the time of renewal subject to underwriting guidelines. be paid only for medical expenses incurred in India, irrespective of the place where the injury was sustained / accident occurred. hallucinogenic substances such as drugs and alcohol. War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defense, rebellion, revolution, insurrection, military or usurped acts, chemical, radioactive or nuclear contamination. Pregnancy or childbirth or in consequence thereof. Congenital internal or external diseases, defects or anomalies or in consequence thereof. Treatments rendered by a Doctor who shares the same residence as an Insured Person or who is a member of an Insured Person s family. Any non-allopathic treatment. For complete list of exclusions please refer to the policy document.
Termination a) The insured member may terminate this certificate of insurance at any time by giving Us written notice or call 24 x 7 CitiPhone or intimate Citibank post internet banking login, and the certificate of insurance shall terminate when such written notice is received. We shall refund a rateable proportion of the premium actually paid in respect of any insured person, provided that the insured person has not made any claim during the policy period. Termination of the certificate of insurance shall not affect any claim filed prior to the date on which termination becomes effective as specified in the notice of termination. b) We may terminate this certificate of insurance on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by the insured member or anyone acting on the behalf of an Insured Person upon 30 days notice by sending an endorsement to the insured member`s address shown in the Schedule without refund of premium Disclaimer For more details on risk factors, terms and conditions please read the sales brochure carefully before concluding the sale. For any claims, queries, escalation surrender, with respect to insurance policies you can contact 24 x 7 CitiPhone, the updated numbers are available on www.citibank.co.in 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 i. Post cancellation/ termination/surrender/ and refund ii. Claims iii. Escalations / service queries Call our Toll Free Line at 1800 3000 1401 Log on to our website www.apollomunichinsurance.com Email us at citicare@apollomunichinsurance.com Write to us at Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana.
Rate Card - GROUP PERSONAL ACCIDENT INSURANCE A Platinum Plan for Citibank Customers Annual Premium Sum Insured Premium Per Person ( in Rs.) with GST ( 18%) 5,00,000 1227 10,00,000 1788 15,00,000 2348 25,00,000 3468 30,00,000 4011 50,00,000 6272 75,00,000 9061 1,00,00,000 11877 2,00,00,000 23087 3,00,00,000 34273 4,00,00,000 45482 5,00,00,000 56717 The above premium is inclusive of applicable Goods and Services Tax ( GST). Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana. Corp. Office : 1st Floor, SCF -19, Sector - 14, Gurgaon - 122 001, Haryana. Regd. Office : Apollo Hospitals Complex, Jubilee Hills, Hyderabad - 500 033, Telangana. Tel: +91 124 4584 333 Fax: +91 124 458 4111 Toll Free: 1800 3000 1401 Email: citicare@apollomunichinsurance.com Website: www.apollomunichinsurance.com 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 Citibank customers shall purely be on voluntary basis. For more details on terms & conditions please read sales brochure carefully before concluding a sale. Tax laws are subject to change. IRDAI Reg No.: - 131 CIN: U66030AP2006PLC051760 UIN: IRDA/NL-HLT /AMHI/P-P/V.1/109/13-14 JSA/M/C16/342 AMHI/MA/H/0002/0117B/012014/P CT/GPA/BR/V0.04/062017
Apollo Munich GROUP PERSONAL ACCIDENT INSURANCE A Platinum Plan for Citibank Customers Application No. : Relationship Manager Code Location To be filled by the Bank Customer Segment: CPC CitiGold Citibanking Suvidha Other (please mention) Please note all sections are mandatory APPLICANT DETAILS Name : (Mr./Ms./Mrs.) Address : First Name Middle Name Last Name City/District: State : Pincode : Nationality : Telephone : Mobile : E Mail : Date of Birth Please tick 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 PROPOSED INSURED(S) DETAILS Sl No. Name Important Political Party Official Relationship to Applicant Gender 1 M/F 2 M/F 3 M/F 4 M/F 5 M/F 6 M/F 7 M/F 8 M/F Note: The sum insured for all dependent children must be same. The sum insured for dependent parents must be same If age of the child is below 21 year, please confirm whether either parents are covered in this policy Yes / No OCCUPATION & INCOME DETAILS Insured 1 Occupation Organization Annual Income (in Rs.) Insured 2 MEDICAL & LIFE STYLE INFORMATION Please answer the below mentioned questions in Yes(Y)/No (N): In relation to each of the insured persons i. Have you in the past or are you currently suffering from any physical or mental defects/impairment/ infirmity/deformity or any condition that may affect your mobility/sight/hearing/speech ii. Have you in the past or are you taking treatment for arthritis, gout, paralysis, epilepsy or any other seizure disorder? Insured 1 Insured 3 Insured 2 Insured 4 Insured 3 Insured 5 Insured 4 Date of Birth (dd/mm/yyyy) Insured 5 Insured 6 Insured 6 D D M M Y Y Y Y Accidental Death Sum Insured (in Rs.) Insured 7 Insured 7 Premium (in Rs.) Insured 8 Insured 8 Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N
In relation to each of the insured persons iii. Does your occupation require you to engage in significant manual labor or hazardous activities or requires handling hazardous material or working at height or with high voltage? If your answer to any of the above is yes, please provide further details Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Insured 7 Insured 8 Y /N Y /N Y /N Y /N Y /N Y /N Y /N Y /N PAYMENT DETAILS Instrument (Credit Card, ECS, Standing Instruction) Instrument Number Instrument Date Name of the Payor as in instrument NA NA Citibank Bank Name IFSC code Amount (Rs.) In case premium is more than Rs.50,000, please provide PAN Details 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. NOMINEE DETAILS In the event of the death of an Insured Person any payment due under the Policy will be payable to the nominee in accordance with the policy terms and conditions. The nominee must be an immediate relative of the Applicant. Nominee for all other persons proposed to be insured shall be the Applicant Nominee Name Relationship to Applicant DECLARATION & WARRANTY ON BEHALF OF ALL THE PERSONS 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, 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/ applicant 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 anytime has attended on the life to be insured/ applicant or from any past or present employer concerning anything which affects the physical and mental health of the life to be assured/applicant and seeking information from any insurance company to which an application for insurance on the life to be assured/ applicant 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 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 the applicant Date: D D M M Y Y Y Y For detailed terms and conditions, please refer insurance policy document VERNACULAR DECLARATION (to be filled only if the proposer has signed in vernacular) Certification in case the proposer has signed in vernacular (to be witnessed by someone other than agent/employee of the company): Name of Applicant : 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. Place: Signature of Applicant Signature of the witness: Date: D D M M Y Y Y Y Name of the witness: Place: Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, ilabs Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana. Corp. Office : 1st Floor, SCF -19, Sector - 14, Gurgaon - 122 001, Haryana. Regd. Office : Apollo Hospitals Complex, Jubilee Hills, Hyderabad - 500 033, Telangana. Tel: +91 124 4584 333 Fax: +91 124 458 4111 Toll Free: 1800 3000 1401 Email: citicare@apollomunichinsurance.com Website: www.apollomunichinsurance.com 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 Citibank customers shall purely be on 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.: - 131 CIN: U66030AP2006PLC051760 UIN: IRDA/NL-HLT /AMHI/P-P/V.1/109/13-14 AMHI/PR/H/0013/0117B/012014/P