Muthoot Finance Business Loan XH Enrolment Form v1

MEMBER ENROLMENT FORM - Xpress Health
The group constitutes of members of ______ who agree to enroll under this Health Plus policy and to make payment of premium in this
regard to Niva Bupa Health Insurance Company Limited.
1- PRIMARY INSURED DETAILS
Name F I R S T N A M E M I D D L E N A M E L A S T N A M E
Gender Male Female Third Gender Date of Birth D D MM Y Y Y Y
Address
City District
State Pin-code
Email Id
Mobile
a. Policy Tenure: 1year 2years 3years 4years 5years

b. Premium with tax (INR): ______________________
c. Maximum payout per policy year: 3 times
d. Coverage: 1 Adult
e. Critical illness covered: 24
Hospitalization days - Minimum Hospitalization days - Maximum Pay-out (INR)

3 5 1st Pay-out
6 8 2nd Pay-out
9 9+ 3rd Pay-out
A. Coverage option :
Title Member Name Gender Date of Birth Relationship

(M/F/ Occupation
(Mr. Ms.) (First, Middle, Last) Third Gender) (DD/MM/YYYY) with Member
Self
2- GOOD HEALTH DECLARATION
I hereby agree to enroll in the policy with the understanding, that I am not suffering from any major/ chronic health problem(s), major
disease/disorder impacting vital organs (Heart, Brain, Kidneys, Lungs, Liver, Pancreas, Spleen, Intestine etc) or deformity other than minor
ailment like Cold, Cough, Fever etc. I hereby also declare that I have never undergone or awaiting any major medical or surgical treatment/
procedure or follow-up. I also understand any non-disclosure in respect to any disease(s), treatment(s) and/or duration of the disease(s)
may result in denial of the claim and/or cancellation of my policy. Pre-existing medical condition(s) will be covered after the waiting period,
as mentioned in the policy T&Cs. Yes No (Do not proceed further)
3- NOMINATION
In the event of your Death, any payment due under the Policy shall become payable to the nominee proposed in the form subject to any
change in nomination as per the terms of the Policy and the receipt of the proceeds by such nominee would be sufficient discharge to the
Company. Following section to be filled by the Member:
Nominee Name Relationship Appointee Details (if nominee is minor)
4- CAUTION
You are obliged to make a full and frank disclosure of all material facts. This obligation of complete and timely disclosure does not end with
the submission of this enrolment form. If there is any change in the information given herein or new information comes to light, then you
must inform us of the same in writing without any delay.
5- COVERAGE
The coverage under this policy is loan linked up to 5 years.
Product Name: Xpress Health, UIN: NBHHLGP22208V022122. 1

6- AUTHORIZATION FOR ELECTRONIC POLICY FULFILLMENT AND SERVICE COMMUNICATIONS
Would you like to protect the environment and help save paper by authorising the company to send all my policy and service related
communication to email ID as mentioned here in the application form? Yes No
7- AUTHORIZATION FOR SERVICE CALLS OR ANY OTHER COMMUNICATION

I hereby provide my consent and authorize the Company to make welcome calls, service calls or any other commercial communication
(electronic or otherwise and/or including but not limited to SMS/WhatsApp) with respect to the proposed or existing policy of Company
from time to time. I also authorize sending any communication for the purposes of marketing and offering of various products and services
of the Company through agent(s) and/or any third party(ies) or any of the product(s) of its affiliates, co-brand partners etc. The said consent
will over-ride any registration on DND registry.
8- CANCELLATION/TERMINATION
Once the Insured ceases to be a member or the policy is cancelled by the Master policyholder or the insurer for any reason whatsoever, the
cover will automatically stand cancelled. However, the Insured under this policy can port to a similar approved retail health policy available
with the company as per 'Portability Guidelines', subject to the Company's underwriting criteria.
9- DECLARATION (Please read carefully and put a check mark against each before signing the proposal form)
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/us are true and complete in all respects to the best of my/our knowledge and that I/We am/are authorized to
propose on behalf of these other persons.
I/We understand that the information provided by me/us 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 further 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 Insurer 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/our proposal including the medical records of the Insured/Proposer
for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory Authority
All the information/particulars in the enrolment form is filled and declared by Customer. Customer has authenticated his/her information
through One Time Password send to his/her mobile number and email.
I agree that this declaration shall be the basis of the decision by Niva bupa Health Insurance Company Limited to cover or not cover me under
insurance.
Dated: Signature of the Customer
Place Name of the Customer
10- MEMBER DECLARATION

(Certification where for any reason, the enrolment form and other connected papers are not filled in by the prospect).
The contents of the enrolment form and connected documents have been fully explained to me and I have fully understood the significance
of the proposed contract. The enrolment form is filled by __________________________________ under my instruction and I found it to be
correct.
Signature of Member
11- VERNACULAR DECLARATION (to be filled only if the proposer has signed in vernacular)
I _________________________________________________hereby declare that I have fully explained the contents of this enrolment form
to the Account holder in the language understood by him/her. The Account Holder has understood and confirmed the same.
Declarant's Name Relationship with the customer
Address City
Pincode Signature of Declarant
12- STATUTORY WARNING (PROHIBITION OF REBATES)
i. 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 maybe allowed in accordance with the published prospectus or tables of the insurer.
ii. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh
Rupees.
Disclaimer: Insurance is a subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company Limited) (IRDAI
Registration No. 145). 'Bupa' and 'HEARTBEAT' logo are registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited under
license. Registered office:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024. CIN NO. U66000DL2008PLC182918. Product Name: Xpress Health | Product UIN:
NBHHLGP22208V022122. Website: www.nivabupa.com. Fax: + 91 11 41743397. Customer Helpline: 1860-500-8888. For more details on risk factors, terms and conditions please read
sales brochure carefully before concluding a sale. Please get in touch with your relationship manager for more details.
2 Product Name: Xpress Health, UIN: NBHHLGP22208V022122.

Muthoot Finance Business Loan XH Enrolment Form v1

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MEMBER ENROLMENT FORM - Xpress Health

1- PRIMARY INSURED DETAILS

a. Policy Tenure: 1year 2years 3years 4years 5years

Hospitalization days - Minimum Hospitalization days - Maximum Pay-out (INR)

Title Member Name Gender Date of Birth Relationship

2- GOOD HEALTH DECLARATION

Nominee Name Relationship Appointee Details (if nominee is minor)

Product Name: Xpress Health, UIN: NBHHLGP22208V022122. 1

7- AUTHORIZATION FOR SERVICE CALLS OR ANY OTHER COMMUNICATION

Dated: Signature of the Customer

Place Name of the Customer

10- MEMBER DECLARATION

Declarant's Name Relationship with the customer

Pincode Signature of Declarant

12- STATUTORY WARNING (PROHIBITION OF REBATES)

2 Product Name: Xpress Health, UIN: NBHHLGP22208V022122.

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