Application No._____________________

PROPOSAL FORM

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 if premium is not received by us in full and in time, or is not realized.

PROPOSER’S DETAILS

Name of proposer : _____________________________________________________________________________ Address : _____________________________________________________________________________ Business of Proposer : _______________________________________________________________________

EXISTING POLICY DETAILS

Policy Period : From: ___________________________________ To __________________________________ Details of coverage : _____________________________________________________________________________ Number of Persons Covered: __________________________________________________________________________ Current Insurer & Branch: ____________________________________________________________________________ For how many years? : _____________________________________________________________________________ Claim Ratio : _____________________________________________________________________________

Year Premium Claim Amount

DETAILS OF THE COVERAGE SOUGHT

Sum Insured Type Individual □ Floater □ Floater Type 1+1 □ 1+2 □ 1+3 □ 1+4 □ 1+5 □ Dependents to be covered Spouse □ Children □ Parents □ Any other_________________ Maternity Coverage Limit Yes □ No □ Maternity Waiting Period Waiver Yes □ No □ New born baby coverage Yes □ No □ Pre-existing Exclusion Waiver Yes □ No □ 30 Days Exclusion Waiver Yes □ No □ 1st Year Exclusion Waiver Yes □ No □ Corporate Floater/Buffer Yes □ No □

If yes, Aggregate limit (In Rs) ___________Limit per member______________ Dental cover Yes □ No □ Specify limit (In Rs) ______________ Critical Illness cover Yes □ No □ Specify limit (In Rs) ______________ OPD cover Yes □ No □ Specify limit (In Rs) ______________ Any other Cover (Specify) _____________________________________

Additional Information [If there is insufficient space to provide additional relevant information, whether as requested or otherwise, please attach extra sheet duly signed]

MEMBER DETAILS (PLEASE ATTACH THE DETAILS IN THE FOLLOWING FORMAT)

Employee Code/

Number Employee Name Designation Location

Name of Insured

Gender Date of

Birth/ Age Relationship

Sum Insured

PAYMENT DETAILS:

Mode of payment: Cash Cheque Electronic Clearing System (ECS)* Others ________________________

Cheque Number

Name of the Premium Payer

Relationship of Payer with Proposer

Bank details Date Amount Pan No.

Please make a A/c Payee Cheque/DD/Pay Order in favor of ‘HDFC ERGO Health Insurance Ltd.' only.* If ECS is selected please submit the standing instruction form available at the branch.

EXCLUSIONS:

This is only a brief summary of the exclusions in your policy, for full list of general exclusions please refer to policy terms and conditions – We are not liable for any treatment which begins during waiting periods except if any Insured Person suffers an Accident, We will not make any payment for any claim in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary in this Policy: 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, nuclear weapons/materials, chemical and biological weapons, radiation of any kind, Any Insured Person committing or attempting to commit a criminal or illegal act, or intentional self-injury or attempted suicide while sane or insane, 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, The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies, Obesity or morbid obesity or any weight control program, where obesity means a condition in which the Body Mass Index (BMI) is above 29 and morbid obesity means a condition where the BMI is above 37, Psychiatric or mental disorders (including mental health treatments and, sleep-apnoea), Parkinson and Alzheimer’s disease, general debility or exhaustion (“run-down condition”); external congenital diseases, defects or anomalies, stem cell implantation or surgery, or

growth hormone therapy, Venereal disease, sexually transmitted disease or illness; “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human immunodeficiency virus) including but not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis, Pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy, Sterility, treatment whether to effect or to treat infertility, any fertility, sub-fertility or assisted conception procedure, surrogate or vicarious pregnancy, birth control, contraceptive supplies or services including complications arising due to supplying services, Dental treatment and surgery of any kind, unless requiring Hospitalisation, Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure or for muscle stimulation by any means (except treatment of fractures and dislocations of the extremities), Nasal septum deviation and nasal concha resection, circumcisions, laser treatment for correction of eye due to refractive error, aesthetic or change-of-life treatments of any description such as sex transformation operations, treatments to do or undo changes in appearance or carried out in childhood or at any other times driven by cultural habits, fashion or the like or any procedures which improve physical appearance, Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident or Illness, Experimental, investigational or unproven treatment, devices and pharmacological regimens, or measures primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies which are not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is required at a Hospital, Convalescence, cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care, long-term nursing care or custodial care, Any non-allopathic treatment, All preventive care, vaccination including inoculation and immunizations, any physical, psychiatric or psychological examinations or testing during these examinations; enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim, Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, documentation and filing, Items of personal comfort and convenience including but not limited to television, telephone, foodstuffs, cosmetics, hygiene articles, body care products and bath additives, barber or beauty services, guest services as well as similar incidental services and supplies, and vitamins and tonics unless vitamins and tonics are certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim, Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is licensed; referral-fees or out-station consultations; treatments rendered by a Medical Practitioner who shares the same residence as an Insured Person or who is a member of an Insured Person's family, however proven material costs are eligible for reimbursement in accordance with the applicable cover, The costs of any procedure or treatment by any person or institution that We have told You is not to be used, The provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy, any treatment and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings, diabetic test strips, and similar products, Any treatment or part of a treatment that is not of a reasonable cost, not medically necessary; non-prescription drugs or treatments, Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment, Any exclusion mentioned in the Schedule or the breach of any specific condition mentioned in the Schedule.

DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS Proposed TO BE INSURED:

I hereby declare and warrant on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects and that there is no other information which is relevant to this application for insurance that has not been disclosed to Apollo DKV Insurance company Ltd. I agree that this proposal and the declarations shall be the basis of the contract between me and all persons to be insured and Apollo DKV Insurance Company Ltd. I further consent and authorize Apollo DKV Insurance Co. Ltd. and/or any of its authorized representatives to seek medical information from any hospital/consultant that I or any person proposed to be insured has attended or may attend in future concerning any disease or illness or injury.

Signature of Proposer: _________________ Date: ______________ (With Official Seal) Place: ______________

I hereby declare and warrant on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects and that there is no other information which is relevant to this application for insurance that has notbeen disclosed to HDFC ERGO Health Insurance Limited. I agree that this proposal and the declarations shall be the basisof the contract between me and all persons to be insured and Apollo Munich Health Insurance Company Ltd. I further consent and authorize HDFC ERGO Health Insurance Limited and/or any of its authorized representatives to seek medical information from any hospital/consultant that I or any person proposed to be insured has attended or may attend in future concerning any disease or illness or injury.

SECTION 41 OF INSURANCE ACT1938 (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 orrenew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of thewhole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any persontaking out or renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordancewith 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 mayextend to ten lakh rupees.

This proposal will be the basis of any insurance policy that we may issue. You must disclose all facts relevant to all persons proposed to be insured that may affect our decision to issue a policy or its terms. Non-compliance may result in the avoidance of the policy. If there is insufficient space for you to provide information, whether as requested or otherwise, please attach a separate sheet. If you are in any doubt, please seek the advice of your insurance advisor.

We would be happy to assist you. For any help contact us at: Email: customerservice@hdfcergohealth.com Toll Free: 1800 102 0333

HDFC ERGO Health Insurance Limited (Formerly known as Apollo Munich Health Insurance Company Limited.) • Central Processing Centre: 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurugram-122016, Haryana • Corp. Off. 1st Floor, SCF-19, Sector-14, Gurugram-122001, Haryana • Registered Off. 101, First Floor, Inizio, Cardinal Gracious Road, Chakala, Opposite P & G Plaza, Andheri (East), Mumbai, Maharashtra 400069 India• Tel: +91-124-4584333 • Fax: +91-124-4584111 • Website: www.hdfcergohealth.com • Email: customerservice@hdfcergohealth.com • For more details onrisk factors, terms and conditions please read sales brochure carefully before concluding a sale. • Tax laws are subject to change. • IRDAI Registration Number–131 • CIN: U66030MH2006PLC331263 • UIN: IRDA/NL-HLT/AMHI/P-H/V.I/107/13-14

ACKNOWLEDGEMENT:

Application Number ________________________ Name of Proposer _____________________________________________________

We acknowledge with thanks the receipt of your application and amount by cash/ cheque/ demand draft/ others ________________________ of amount Rs. ______________________.

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 15 days.

Signature of the receiver and Official Seal: _______________________________ Date: ______________

We would be happy to assist you. For any help contact us at: Email: customerservice@hdfcergohealth.com Toll Free: 1800 102 0333

HDFC ERGO Health Insurance Limited (Formerly known as Apollo Munich Health Insurance Company Limited.) • Central Processing Centre: 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurugram-122016, Haryana • Corp. Off. 1st Floor, SCF-19, Sector-14, Gurugram-122001, Haryana • Registered Off. 101, First Floor, Inizio, Cardinal Gracious Road, Chakala, Opposite P & G Plaza, Andheri (East), Mumbai, Maharashtra 400069 India• Tel: +91-124-4584333 • Fax: +91-124-4584111 • Website: www.hdfcergohealth.com • Email: customerservice@hdfcergohealth.com • For more details onrisk factors, terms and conditions please read sales brochure carefully before concluding a sale. • Tax laws are subject to change. • IRDAI Registration Number–131 • CIN: U66030MH2006PLC331263 • UIN: IRDA/NL-HLT/AMHI/P-H/V.I/107/13-14