PROPOSAL FORM

AROGYA TOP UP POLICY

Guidelines for completion of the form: 1. Please answer all the questions fully and accurately. Where any question does not apply, please mention clearly that
the same is not applicable. 2. Insurance is a contract of Utmost Good Faith requiring the Proposer not only to disclose all material facts but also not to
suppress any material facts in response to the questions in the proposal form. If you think any fact is material, please disclose it. 3. The Policy shall become
voidable at the option of Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure of any material
particular to the proposal form/ personal statement, declaration and connected documents or any material information having been with held by the
Proposer or anyone acting the on Proposer’s behalf. 4. Kindly contact SBI General Offices or Agents for any doubts or clarifications on the proposal form.
Important Information: Health Check-Up/ Medical Examination may be required for all persons aged 55 years and above, and pre-acceptance medical tests
is at the cost of the Proposer. However, if the proposal is accepted, the Insurer will reimburse 50% of the cost incurred towards the medical tests so
undertaken at the advice of the Insurer.

FOR OFFICE USE

Quote No.: Inward No.:

Receipt No.: Receipt Date: D D M M Y Y Y Y

INTERMEDIARY'S DETAILS (* Mandatory Fields if Sales Channel Type selected is Banca)

Segment Type: Corporate Retail SME Business Sector: Urban Metro Rural Village Social

Business Type: New Roll-Over Renewal Sales Channel Type: Banca Agency Direct

Sales Channel Code: Specified Person's / Intermediary's Code*:

Specified Person's /
Intermediary's Name*:

GSTIN/ISDN: IF APPLICABLE

PART I - PROPOSER’S DETAILS

1. Name: S U R N A M E M I D D L E N A M E F I R S T N A M E

Gender: Male Female Others Date of Birth: D D M M Y Y Y Y

Marital Status: Single Married Others

Occupation: Self Employed/ Agriculture

Salaried Business Student Retired Others (specify) _________)
Professional

2. Address where you Plot No./Door No.: Building name:

normally reside
(Communication Address): Road: Area:

City: Pincode:

State: Phone No.:

Email ID:

3. Address of the Insured Plot No./Door No.: Building name:

if different from above
(Permanent Address): Road: Area:

City: Pincode:

State: Phone No.:

Email ID:

4. Policy Term: 1 Year 2 Years 3 Years

5. Policy Period: From: D D M M Y Y Y Y To: D D M M Y Y Y Y

6. Total No. of Persons to 7. Are you one among the Insureds Covered below? Yes No
be covered:
8. Nominee’s Name:

9. Nominee’s Relationship
with the Proposer:

Disclaimer: SBI General Insurance Company Limited I Corporate & Registered Office: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai - 400 099. | For
more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before conducting a sale. I For SBI General Insurance
Company Limited IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | SBI Logo displayed belongs to State Bank of India and used by SBI General Insurance
Company Limited under licence. | UIN: SBIHLIP22137V032122 | URN: SBIG/ATUP/V.01/22122014.
11
Call (Toll Free) | 1800 22 1111 | 1800 102 1111 | www.sbigeneral.in
10. If the Nominee is a minor,
Name of the Appointee and his
relationship with the Nominee:
Date of Birth: D D M M Y Y Y Y

11. Aadhaar Card No.: 12. PAN: / Form 60:

13. Corporate: Yes No 14. GSTIN/ISDN: IF APPLICABLE

DETAILS OF COVERAGE SOUGHT

Note: By Family we mean You, Your legal Spouse, Legal & Dependent Children, Dependent Parents and Parents-in-law.

Policy Term (Please tick) 1 Year 2 Years 3 Years

Type of Policy (Please tick) Individual Family Non-floater Family Floater

Sum Insured (Please specify) Deductible (Please specify):

Do you want to reinstate Sum Insured? Yes No

ELECTRONIC INSURANCE ACCOUNT DETAILS SECTION

I want Arogya Top Up Policy and related information in: Physical Format e-Format (electronic); as & when applicable.

Choose your Insurance Repository (For those selecting e-Format)

NSDL Data Management Ltd. CDSL Insurance Repository Ltd. Karvy Insurance Repository Ltd. CAMS Repository Services Ltd.

I have an e-Insurance Account & the No. is

My CKYC No. (Central Know Your Customer Registry Number) is (If available).

PART I - MEMBERS PROPOSED FOR INSURANCE

Name Gender DOB Marital Relationship with Other Insurance Sum Deductible
Status the Proposer Insured
Yes No

PART II - OTHER / CURRENT HEALTH INSURANCE INFORMATION

PART III - DETAILS OF ILLNESS/ACCIDENT

Do any of Insured suffer from physical /mental disease or infirmity or medical complaints or deformity? Yes No
If yes, name the Insured and the Disease.

Do any of the Insured smoke? Yes No

Do any of the Insured consume any other type of tobacco including betel nut? Yes No

Do any of the Insured consume alcohol? Yes No

PAYMENT DETAILS (Claim/Refund amount will be deposited in this Bank Account only unless changed subsequently)
Please draw your Cheque (A/c payee only) in the name of “SBI General Insurance Company Limited” (*Mandatory fields)
Cheque No./DD No.: Amount: Date: D D M M Y Y Y Y

Bank Name: Branch:

Bank Account No.*: IFSC Code*:

Period of Insurance: From: D D M M Y Y Y Y To: D D M M Y Y Y Y

Disclaimer: SBI General Insurance Company Limited I Corporate & Registered Office: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai - 400 099. | For
more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before conducting a sale. I For SBI General Insurance
Company Limited IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | SBI Logo displayed belongs to State Bank of India and used by SBI General Insurance
Company Limited under licence. | UIN: SBIHLIP22137V032122 | URN: SBIG/ATUP/V.01/22122014.
21
Call (Toll Free) | 1800 22 1111 | 1800 102 1111 | www.sbigeneral.in
 AML GUIDELINES
I/We hereby confirm that all premiums have been/ will be paid from bona fide sources and no premiums have been/will be paid out of proceeds of crime related to any of the offence
listed in Prevention of Money Laundering Act 2002. I understand that the Company has the right to call for documents to establish source of funds. The Insurance Company has the
right to cancel the Insurance Contract in case I am/ have been found guilty by any competent court of law under any statues, directly or indirectly governing the Prevention of
Money Laundering in India.
Nationality: Indian/Non- Indian
If Non-Indian, please specify the Country: __________________________________________________________________
Type of Organisation: Corporation/Government/Non-Governmental Organisation/Society/Trust/Partnership/ International Organisation/Cooperative/Section 8 Companies.

SECTION 41 OF INSURANCE ACT, 1938

1. No person shall 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 whole or part of the commission payable or any rebate of the premium shown in 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 Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend up to ` 10 Lacs.

AGENTS DECLARATION

I,___________________________________________________ (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorised 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 favour 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.

Licence No. ______________________________________

Date: D D M M Y Y Y Y Place: Signature of Agent:

DECLARATION BY PROPOSER
1. I/We hereby declare on my/our behalf and on behalf of all the persons proposed to be Insured, that the above statements, answers and/ or particulars given by me/us are true and
complete in all respects to the best of my/our knowledge and that I/We am/are authorised to propose on behalf of these other persons. 2. I/We understand that the information
provided by me/us will form the basis of the 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. 3. I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the person to be
Insured / Proposer after the proposal has been submitted but before communication of the risk acceptance by the Company. 4. I/ We declare that I/ We consent to the Company
seeking medical information from any doctor or from a hospital who at anytime 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 Insurance Company to which 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. 5. I/We authorise the
Company to share information pertaining to my proposal including the medical records for the sole purpose of underwriting the proposal and/or
claims settlement and with any Governmental and/ or Regulatory Authority. 6. I/We aware of premium loading, (if any declared above) for habit’s as declared/ mentioned
by me /us above.

Date: D D M M Y Y Y Y Place: Signature of Proposer:

Name of the Proposer:

DECLARATION (If signed in vernacular language / If you have affixed thumb impression above)

Applicable where the Proposer is illiterate or is suffering from a disability due to which writing is restricted or where the Proposer has signed in vernacular language.

(Note: The below must be witnessed by someone other than the Advisor/Employee of the Company).

I/We certify that the product applied for by me/us and the contents of the Proposal Form have been clearly explained to me/us and I/We have fully understood them. I/We further certify
that the replies in the Proposal Form have been recorded as per the information provided by me/us.

I, (Full name of the witness) ________________________________________________ (Relationship with the Proposer) _____________________________ adult and inhabitant of (City)
___________________and residing at _______________________ do hereby certify that I have read out and explained the contents of the Proposal Form and all other documents
incidental to availing the Insurance Policy from SBI General Insurance Company Ltd., to the Proposer/Primary Insured and he/she/they have understood the same. I declare that
whatever I have stated herein above is true and correct to the best of my knowledge and belief.

Date: D D M M Y Y Y Y Place:
Signature of the Witness

Signature/Thumb impression of the Proposer

Disclaimer: SBI General Insurance Company Limited I Corporate & Registered Office: Fulcrum Building, 9th Floor, A & B Wing, Sahar Road, Andheri (East), Mumbai - 400 099. | For
more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before conducting a sale. I For SBI General Insurance
Company Limited IRDAI Reg. No. 144 dated 15/12/2009 | CIN: U66000MH2009PLC190546 | SBI Logo displayed belongs to State Bank of India and used by SBI General Insurance
Company Limited under licence. | UIN: SBIHLIP22137V032122 | URN: SBIG/ATUP/V.01/22122014.
31
Call (Toll Free) | 1800 22 1111 | 1800 102 1111 | www.sbigeneral.in