Tata AIG Group EMI Protect

UIN: TATHLGP20116V011920

ENROLMENT FORM
Application No. /Loan Account No.: Master Policy Reference no.:

This is an application for Insurance & will form the basis of the policy certificate that We may issue. Every information, this application seeks is
important & mandatory. Please read all questions and answer them carefully. You must provide complete and correct information. Incom-
plete/incorrect/partially correct information may lead to cancellation of proposal and policy certificate even if it is issued. 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 premium is not received by Us in full
and in time, or non-fulfillments of additional information requested by us, if any or if the proposal is under-process & claim arises in the
interim period before the decision on the proposal is given by us.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.

1. Proposer/Insured Person’s Information Please fill-up this form in CAPITAL LETTERS

Name: (Mr./Mrs./Ms)
First Name Middle Name Last Name

Date of birth: Gender:

Occupation: Salaried Self-employed Others

Address for communication:

District: City: State: Pin code:

Tel (O): Mobile:

Email Id: Unique id no.:

Loan Details:

Tata AIG Group EMI Protect UIN: TATHLGP20116V011920

Type of loan Loan Tenure Loan Amount Date of loan sanction Date of disbursement Disbursal Amount

Note: Policy tenure > 1 year is applicable in case of credit linked policies

2. INSURED PERSON’S DETAILS

Name of the Insured persons Relationship with Applicant Date of birth Occupation Gender Unique Id no.

3. MEDICAL AND LIFESTYLE INFORMATION

Please answer the below mentioned questions in Yes (Y) / No (N).

Please answer the below mentioned questions in Yes (Y) / No (N). Y N

Has any person to be insured suffered/suffering from any pre-existing illness/medical/surgical condition?

Has any person to be insured taking medications on regular basis?

Has any person to be insured awaiting any treatment, medical or surgical, or attending any follow up for any disease/
condition/ailment/injury/addiction?

Pre-existing disease/Disability details, if any:

In case of any the proposed insured marks yes to any of the above question or declare any pre existing disease/disability, decision to
accept the proposal with loading/exclusions or rejecting the proposal will be taken by the health underwriting team.

1
TATA AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 | E-mail: customersupport@tataaig.com | Website: www.tataaig.com
IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Group EMI Protect
UIN: TATHLGP20116V011920

4. PLAN DETAILS

Group EMI Protect: Please fill the below details

Plan Type Policy Tenure Post Tax Premium (in Rs.)

Plan Benefit Coverage Details 2 Years 3 Years 4 Years 5 Years

Inpatient Hospitalization 05 - 09 Days of per Hospitalization - Rs. 4,200

A Benefit 10+ Days of per Hospitalization - Rs. 8,400 ₹ 674 ₹ 968 ₹ 1,233 ₹ 1,470

Accidental Death Rs. 70,000

Inpatient Hospitalization 05 - 09 Days of per Hospitalization - Rs. 7,500

B Benefit 10+ Days of per Hospitalization - Rs. 15,000 ₹ 1,204 ₹ 1,729 ₹ 2,202 ₹ 2,625

Accidental Death Rs. 1,25,000

Inpatient Hospitalization 05 - 09 Days of per Hospitalization - Rs. 12,000

C Benefit 10+ Days of per Hospitalization - Rs. 24,000 ₹ 1,926 ₹ 2,766 ₹ 3,524 ₹ 4,200
Accidental Death Rs. 2,00,000

For coverage details & terms & conditions kindly refer the policy wordings

5. NOMINEE DETAILS

Nominee Name _________________________________________________Relationship with the Insured Person __________________________________

In the event of the death of the 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 Insured Person.

6. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

Tata AIG Group EMI Protect UIN: TATHLGP20116V011920

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 payment 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 doctor or hospital who/which 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 whom 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.
I/We authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for
the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.
I/We hereby declare that the above health declaration is good and answer to all health questions is “N”.

It is hereby declared and agreed, I/we declare and agree that upon any monies becoming payable under this Policy the same shall be
paid by the Company to the Bank/ financial/lending institutions against the loan amount and such part of any monies so paid as may
relate to the interests of other parties insured hereunder shall be received by the Bank/ financial/lending institutions as Agents for such
other parties. That the receipts of the Bank/ financial/lending institutions shall be complete discharge of the Company therefore and
shall be binding on all the parties insured hereunder.

Signature of the Applicant:

Date: Place:

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TATA AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 | E-mail: customersupport@tataaig.com | Website: www.tataaig.com
IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
Tata AIG Group EMI Protect
UIN: TATHLGP20116V011920

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have
understood these and confirm to abide by the policy terms & conditions.

Signature of the Proposer: _______________________________________________

Name & Signature of agent/intermediary/Specified Person: __________________________________

Code: ____________________________

Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print)

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to
the proposer who has understood and confirmed the same.

Signature/Thumb impression of the Proposer: ________________________________________________

Name & Signature of agent/intermediary/Specified Person: _________________________________________

Signature of the Proposer: ________________________________

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
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 insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh
rupees.

For office use only - Employee ID: ______________________________________ Partner Reference ID ____________________________________________

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions please read policy document carefully before concluding a sale.

Tata AIG Group EMI Protect UIN: TATHLGP20116V011920

3
TATA AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 | E-mail: customersupport@tataaig.com | Website: www.tataaig.com
IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425
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Tata AIG Group EMI Protect
UIN: TATHLGP20116V011920
CUSTOMER ACKNOWLEDGEMENT
Application Number: ______________________________________________ Date: ______________________
Name of the Proposer_______________________________________________________________
We acknowledge with thanks the receipt of your application for Tata AIG Group EMI Protect and amount by cash/cheque/Demand Draft/others
________________________________ of amount of Rs._______________________. Neither the submission to us of this completed enrollment form for
insurance nor any payment towards this application 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 proposal is not accepted by us or premium is not received by us in full and in time, and/or additional information
requested by us. Failure to deposit the entire premium or furnish additional information requested by us within 15 days from the date of
proposal, we shall cancel your application and refund the premium paid without any interest. If we do not accept the proposal, we will inform
you and refund any payment received from you, towards this application, without interest within next 10 days.
We shall have no liability to make any payment under the Policy if proposal is under-process & claim arises in the interim period before the
decision on the proposal is given by us.
TATA AIG General Insurance Company Limited
Registered Office: Peninsula Business Park, Tower- A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013, Maharashtra, India
24x7 Toll Free No: 1800 266 7780 | E-mail: customersupport@tataaig.com | Website: www.tataaig.com
IRDA of India Registration No: 108 | CIN: U85110MH2000PLC128425