NBRF318213092416 | CANA

MEMBER ENROLLMENT FORM – HDFC Life Group Credit Protect Plus

Smart Medical Questionnaire
IMPORTANT NOTE: Any cancellation and alteration must be countersigned by Life to be Insured. Please do not sign blank Proposal form.

Bank Emp Code (LG) ______________________________________ Bank Emp Code (LC) ______________________________________
Options: 3D Life Option Extra Life Option Terminal Life Option Critical Life Option 1 Critical Life Option 2 Life Disability Option
Segment (SAB/KGC) Facility Sum Assured (INR) Premium Amount (INR) Policy Term(Yrs) Type of Cover Loan Acc. No/Proposal No
CC-Crop Loan CC
OD CC
TL TL
DOD TL
*Note: On opting for 3D benefit, the member will be covered for death benefit, life disability and Critical Life. The coverage for Critical Life (Critical Illness) will be for policy tenure or 20 years whichever is lesser.

Applicant Status: Primary Borrower Co borrower Main benefit: level decreasing

Loan type: ___________ Loan disbursal date: __________________
DD/MM/YYYY Loan amount(`): ____________ Loan Account Number: _____________ Loan Term: months

I/we agree and understand the following:

My/ our loan is in the name of: ________________________________________(borrower), _______________________________________________________________________(co-borrower/s)
Insurance cover is being taken in the name of: ________________________________________________________________________________________________(member names to be inserted)
Type of cover: Single life Joint Life

ABHA (Life to be Assured) _______________________________________________ ABHA (Co-Borrower/Joint Life) _____________________________________________________________________

Declaration for Ayushman Bharat Health Account (ABHA) : I/we willingly grant my/our explicit consent to HDFC Life Insurance Co. Ltd. to collect, store, process, transfer and archive my/our ABHA (Ayushman Bharat Health Account) information. Furthermore,
I/we authorize the sharing of this information with HDFC Life Insurance Co. Ltd.'s reinsurers and their third-party vendors for various purposes including but not limited to underwriting, claims processing, risk assessment, fraud prevention, customer service
and outsourced activities linked to the insurance services to be rendered to me by HDFC Life Insurance Co. Ltd. I/we acknowledge that I/we have the right to opt out of this consent at any time by contacting HDFC Life Insurance Co. Ltd.

Personal Details of Life to be Assured

Full Name: F I R S T M I D D L E L A S T
Mr. Mrs. Ms. Dr.
DD/MM/YYYY
Date of Birth:_______________ Gender: Male Female Transgender Gross Annual Income (`):
Country of Residence________________ (For Students & Education Loan, Country of study to be entered) Mobile No: Email Id:_________________________________

Education: Post Graduate Graduate Diploma 12th pass 10th pass Below 10th Illiterate Marital status of Life to be Assured: Married Unmarried Widower Single
Armed/Police
Present Occupation: Salaried Self Employed Professional Forces Agriculture Fire Service Retired Student Housewife Unemployed Merchant Marine
(If you are working in navy/police/armed/air force/fire service, Merchant Marine please attach appropriate questionnaire.)

Nominee / Appointee:
Full Name Date of Birth Relationship to Share (%)
Nominee 1: DD MM Y Y Y Y Life Assured
Nominee 2: DD MM Y Y Y Y Life Assured
Appointee 1: DD MM Y Y Y Y Nominee (if nominee is below 18 yrs of age) N/A

Particulars of Legal Guardian (if Life to be Assured is a minor): Mr/Mrs. _________________________________________________________________________________________________________

Date of Birth: D D M M Y Y Y Gender: M F Transgender Relationship with Life to be Assured ____________________

Medical Questionnaire Life to be Assured

1. Have you ever suffered or are currently suffering from: (a) Chest Pain or heart attack or any other heart disease (b) Cancer, tumor, growth or cyst of any kind (c)Stroke, paralysis Epilepsy, any psychiatric / mental disorder, disorder of
brain/nervous system or any kind of physical disabilities (d) Asthma, Tuberculosis, pulmonary obstructive disease or other lung disorder (e) Diseases or disorder of muscles, bones or joints, arthritis or blood disorder, anemia or any
Yes No
endocrine disorder, congenital disorder, genetic disorder (f) Diseases of the kidney, digestive system (stomach, pancreas, gall bladder, intestine), liver, Hepatitis B or C or HIV/AIDS infection or sexually transmitted disease (g)
Diabetes, high blood pressure (h) Any Other disorders. If Yes, then provide details of the medical condition_____________________
2. During the last 5 years have you undergone any major surgery or been hospitalized for more than one week or have taken leave from work for more than 5 consecutive days due to any medical reason? If Yes, then provide details
Yes No
of the medical condition _____________________?
3. Are you taking any medication or has a doctor ever attended to you for any conditions, diseases or impairment not mentioned above (except for cough or cold)? If Yes, then provide details of the medical condition Yes No

4. Has more than one of your parents and siblings died before the age of 60 years as a result of heart attack, stroke, cancer, diabetes, HIV, kidney failure or any other chronic or hereditary / familial disorders? If Yes, then provide Yes No
details of the medical condition_____________________
5. Have you ever been declined, deferred, and accepted at special terms, had cover reduced or had exclusion imposed for any insurance cover in India or abroad? If Yes, then
Yes No
provide reasons? _____________________________
6. Do you take part in any adventurous sports or hobbies? (like paragliding, mountaineering, deep sea diving, motor racing, bungee jumping, etc.) If Yes, then provide details _______________________ Yes No

7. Do you currently smoke more than 10 cigarettes / bidis per day or chew more than 5 pouches of tobacco per day or consume alcohol more than (wine- 180 ml, Beer – 350 ml, Hard liquor – 45 ml) a day or using / ever used any Yes No
Narcotics or any other drug?
8. Is your occupation or business associated with any hazard (e.g. exposure to chemical substances/hazardous materials/harmful dust or gases/ explosives/ working at heights/ handling heavy machinery etc.)? Yes No
If Yes, then provide details ______________________
9. For Female Lives: Yes No
(a) Are you currently pregnant at 20 weeks or more or have you ever undergone abortion, miscarriage, or any complications during pregnancy?
Yes No
(b) Have you given birth within the last 12 weeks?
(c) Have you ever had any disease of breast, uterus, cervix, ovaries or any other part of the reproductive system? Yes No
10. Have you ever been or currently being investigated, charge sheeted, prosecuted or convicted or acquitted or having pending charges in respect of any criminal/civil offences in any court of law in India or abroad? If Yes, then provide details Yes No
_____________________
11. Do you have any group risk cover as a scheme member through the same Master Policy holder (lender) or any other Master Policy holder where HDFC Life is an insurer? If yes, specify sum assured. Rs __________________ Yes No

12. Are you a Politically Exposed Person? If Yes, then provide PEP Questionnaire

Declaration of Life to be Assured

•I understand, agree and confirm that these statements and this declaration are basis of the contract between the insurer and the policyholder. Subject to Section 45 of the Insurance Act 1938 as amended from time to time, if any untrue statements are contained herein or there has been any non disclosure of any material fact, the policy to be issued by the insurer in the name of the policyholder may be treated as void as far as I am concerned. •I confirm that I have read
and understood, the rules and any additional rules of the plan, the standard policy provisions and any additional provisions that govern the policy to be issued by insurer in the name of the policyholder and on my life, and I agree and confirm that the same shall be binding on me. •I authorise the policyholder to disclose to the insurer such particulars as they may require including the details given above and any changes to the same, pay the premium payable on my
behalf /collected from me to the insurer. •I understand that any statutory levy or charges including any indirect tax may be charged to me either now or in future by the insurer and I agree to pay the same. •I understand that HDFC Life Insurance Company Limited (HDFC Life) has the right to reject a proposal without giving reasons thereto and confirm to give an undertaking that I shall not raise any claims thereof. •I understand the significance of the contract and that
the contract will be governed by the provisions of the Insurance Act 1938 as amended from time to time and that the same will not commence until written acceptance of this application issued by the insurer on its normal terms and conditions is received. •I further agree that if after the date of submission of the proposal but before the issuance of Policy (i) there is an adverse change in my occupation, financial condition, health condition, which will affect the decision
of the Company in underwriting risk or (ii) if the proposal for assurance or an application for revival of the policy made to any insurer on my life or the Life to be assured is withdrawn or dropped, deferred, declined or accepted on terms other than as proposed, I shall forthwith intimate the same to the company in writing and failure to do so shall lead to a decision as per the applicable terms and conditions of the policy. •I hereby declare that the content of the form and
document has been fully explained to me and I have fully understood the significance of the proposed contract. •I understand and agree that in case any error, omission, incorrect information, blank forms, etc. are detected at the claim stage because of lapses on the part of the scheme member, such claims shall be treated as invalid by the insurer and the claim payout shall not be processed. •I understand that any If any of the requirement/s raised by the insurer including
further requirements pertaining to medical tests/reports/investigations are not completed within three months from the date when the member enrolment details were shared by the Master Policy Holder (MPH) with the insurer, the received premium amount for the said enrolment, would be refunded and the respective member's enrolment shall be deemed as withdrawn. •I declare and hereby consent and authorize the Company or any of its authorized representatives
to seek medical information from any doctor or from a hospital who at anytime has attended me or from any past or present employer concerning anything which affects my physical or mental health and seeking information from any insurance company to which an application for insurance has been made for the purpose of underwriting the proposal and /or claim settlement. In the event of change in age from the declared age before the risk commence Date,
the sum assured may be revised to adjust for the possible premium shortfall. • I acknowledge that,in conjuction with obtaining the loan from the Master Policyholder,i am taking an insurance cover from HDFC Life to safeguard myself against a loan default on the occurence of any contingent event as cover under the COI issued to me. Further ,I hereby grant explicit constent to the MPH for including the insuarnce premium amount payable
by me in the loan EMI(subject to confirmation by MPH)and paying it directly to the insurace company

Signature/Thumb impression
Date:____________
DD/MM/YYYY Date:____________
DD/MM/YYYY Signature/Thumb impression: _______________________
(Life to be Assured)
Place:___________ Place:___________ (Witness)
Assignment as per Section 38 of The Insurance Act, 1938 as amended from time to time
I do hereby declare that I have received a loan from M/s ______________________________________________________ (“Master Policyholder”). In order to secure the said loan, I hereby agree to assign the insurance cover provided to me under the above
referenced Master Policy and the Certificate of Insurance in favor of the Master Policyholder as per Section 38 of The Insurance Act, 1938 as amended from time to time. The said assignment is to the extent of the outstanding loan amount as per outstanding
loan schedule to be issued by the Master Policyholder on the date of occurrence of the contingent event. I hereby agree and confirm that I shall inform my beneficiary/ nominee about the existence of this assignment.

Signature/Thumb impression
Date:____________
DD/MM/YYYY Place:___________ (Life to be Assured) DD/MM/YYYY
Date:____________ Place:___________ Signature/Thumb impression: __________________
(Witness)

Declaration made by Declarant where Life to be Assured has;

a) affixed his/her thumb impression; OR b) signed in vernacular; OR c) not filled the application
“I hereby declare that I have fully explained the above questions and contents of the Member Enrollment Form to the Member and the Joint Life Assured (if any) and I have truthfully recorded the answers given by the Member and the Secondary / Joint Life
Assured (if any) and that the Member and the Secondary / Joint Life Assured (if any) has affixed the thumb impression above after fully understanding the contents there of.”
Name of the Declarant___________________________ Name of the Witness___________________________
Address of the Declarant_________________________ __________________________ Address of the Witness__________________________ __________________________
Signature/Thumb impression Signature/Thumb impression
Date:_________________
DD/MM/YYYY Place:_________________ (Declarant) Date:_________________
DD/MM/YYYY Place:_________________
(Witness)
“I certify that the contents of the form and documents have been fully explained to me by Mr. / Mrs.:______________________________ and I have understood the significance of the proposed contract.
Signature/Thumb impression
Date:____________
DD/MM/YYYY Place:___________ (Life to be Assured)

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor: I/We hereby declare that the content of the form and document filled up by the Member or Joint Life Assured is accurate and true to
my/our knowledge.
Name of the Witness___________________________
DD/MM/YYYY __________________________ Address of the Witness__________________________ __________________________
Date:____________ Place:___________ (Signature / Thumb Impression of the Legal Signature/Thumb impression
Date:_________________
DD/MM/YYYY Place:_________________
Guardian (if the Life Assured is a Minor) ) (Witness)
HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860-267-9999 (Local charges apply) | 022-68446530 (STD charges apply). Available Mon-Sat from 10 am to 7 pm. DO NOT prefix any country code e.g. +91 or 00. | Email – service@[Link] | nriservice@[Link] (For NRI customers
only) Visit – [Link] UIN: 101N096V04