6/17/25, 4:15 PM Personal Loan - Insurance Consent Form

Confirmation for Insurance/VAS product

Applicant Details

Name of the Applicant : YADAV MADHUKIRAN

Date of birth : 2000-07-22

Mobile :9014373552

Personal Email Id : NA

Current Residence address :S/O KISHTAPPA 76 97 493 UP WASKER SECTION COLONY M KURNOOL N R NAGAR KURNOOL
KURNOOL KURNOOL ANDHRA PRADESH INDIA KURNOOL KURNOOL ANDHRA PRADESH 518001

Landmark : N R NAGAR

City : KURNOOL

Pincode : 518001

State : ANDHRA PRADESH

PRODUCT NAME - HEALTH PLUS

Sum Insured : ₹ 65000.0

Tenure (in Yrs) : 12.0

Premium (Inclusive of applicable taxes) : ₹ 899.0

Plan Option : NA

Sum Assured Type : NA

Consent Details : Accepted IP Address : 2409:4070:4209:21f2::14f1:40b0 Language Name : English Application Number : B2C000131932767 Date & Time : 2025-06-17 16:14:21 Mobile Number : 9014373552 Email ID :

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Authorization - I do hereby authorize and instruct Niva Bupa Health Insurance Co. Ltd. (formerly known as Max Bupa Health Insurance Co. Ltd.) to refund, the premium
(in full or prorated as the case may be) to the Master Policyholder, in event of cancellation/withdrawal of the insurance cover to me/us under the group policy of the
Master Policyholder. In event Niva Bupa Health Insurance Company limited refunds the premium amount as per instruction above, it shall be considered full and
complete discharge of any liability by Niva Bupa Health Insurance Company limited towards me and I shall not have any objection to such refund subsequent to
payment as per above instructions.

# Conditions Apply. Please refer to the 'Insurance Disclaimer and Customer Declaration' section below before concluding a Sale.
Product Name: Niva Bupa Health Plus | UIN: NBHHLGP22157V032122

Date : 2025-06-17

Place : NA Borrower Signature

PRODUCT NAME - BAJAJ ALLIANZ LIFE GROUP SAMPOORNA JEEVAN SURAKSHA

Sum Insured : ₹ 136327.65

Tenure (in Yrs) : 36.0

Premium : ₹ 4477.0

Premium Payment Option : Single

Plan Option : Base

Sum Assured Type : Level

Premium Payment Frequency : Single

Cover Type : Single Life

DECLARATION OF GOOD HEALTH: - I am in sound state of health / I have never undergone, or expect to undergo any surgical procedure for any illness, ailment, disease
or disability / I have never suffered from, or not suffering from any disease/ailment requiring any form of medication for more than 7 consecutive days, nor been
absent from work for more than 7 days / I do not engage or intend to engage in any business, sport or occupation of a hazardous nature and I do not have any history
of conviction under any criminal proceedings in India or abroad / My any proposal for insurance, or revival of policy on my life to this company or any other insurance
company never been postponed/declined/accepted on terms other than proposed / For Female Lives only - I am not pregnant / I have never suffered from any disease
of the breast, uterus, cervix, ovaries or any other part of the reproductive system

✔ Yes

No

Assignment - I have received/applied a loan from M/s Bajaj Finance Ltd. In order to secure the said loan, I hereby assign all the rights and interest in the life insurance
policy issued pursuant to the abovementioned application to the Assignee (Bajaj Finance Limited) and submission of this request shall be treated as adequate notice
of assignment to Bajaj Allianz Life Insurance Company Ltd. (“Company”). In the event of my death during the term of the policy, the benefits, as per the policy terms
and conditions, will be paid to the Assignee to the extent of the liability against me that exists with the Assignee, and balance amount, if any, shall be paid to my
nominee. I hereby indemnify and keep indemnified the Company and its directors, employees and successors and hold them harmless from all the liabilities or claims
that may arise in future pursuant to such assignment..

# Conditions Apply. Please refer to the 'Insurance Disclaimer and Customer Declaration' section below before concluding a Sale.
Product Name: Bajaj Allianz Life Group Sampoorna Jeevan Suraksha | UIN: 116N166V01

Date : 2025-06-17

Place : NA Applicant's Signature

Consent Details : Accepted IP Address : 2409:4070:4209:21f2::14f1:40b0 Language Name : English Application Number : B2C000131932767 Date & Time : 2025-06-17 16:14:21 Mobile Number : 9014373552 Email ID :

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INSURANCE DISCLAIMER & CUSTOMER DECLARATION

1. I/We provide my/our consent voluntarily for enrolling as a member of group insurance offered to me by the above insurer under the master policy of Bajaj Finance
Limited.

2. I/We 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/We am/are concerned.

3. I/We confirm that I/We 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/our life, and I/We agree and confirm that the same shall be binding on me/us.
I/We authorize 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/our behalf /collected from me/us to the insurer. I/We understand that any statutory levy or charges including any indirect tax may be charged
to me/us either now or in future by the insurer and I/We agree to pay the same

4. I/We further agree that if after the date of submission of the proposal but before the issuance of Policy

there is an adverse change in my/our occupation, financial condition, health condition, which will affect the decision of the Insurer in underwriting risk or
if the proposal for assurance or an application for revival of the policy made to any insurer on my/our life or the Life to be assured is withdrawn or dropped,
deferred, declined or accepted on terms other than as proposed, I/We shall forthwith intimate the same to the insurer in writing and failure to do so shall lead to
a decision as per the applicable terms and conditions of the policy.

5. I/We understand that insurer has the right to reject a proposal without giving reasons thereto and confirm to give an undertaking that I/We shall not raise any claims
thereof. I/We 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.

6. I/We hereby declare that the content of the form and document has been fully explained and given by me/us and I/We have fully understood the significance of the
proposed contract.

7. I hereby declare that the above statements and/or particulars given by me are true and complete in all respects to the best of my knowledge.

8. I understand that the information provided by me will form the basis of insurance policy, is subject to Board approved underwriting policy of the insurance company
and that the policy will come into force only after full receipt of premium chargeable.

9. I further declare that I will notify in writing any change occurring in the occupation or general health after the proposal has been submitted but before communication
of the risk acceptance by the Company.

10. I declare and further consent to the Company seeking medical information from any doctor or hospital who/which at any time has attended me or from any past or
present employer concerning anything which affects my physical or mental health and seeking information from any insurer to whom an application for insurance has
been made for the purpose of underwriting the proposal and/or claim settlement.

11. I authorize the Company to share information pertaining to my proposal including the medical records for the sole purpose of underwriting the proposal and/or claim
settlement and with any Governmental and/or Regulatory Authority

12. 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 hereby expressly authorize BFL to send me
communications regarding loans, insurance and other products from BFL, its group companies and/or third parties through telephone calls / SMSs / emails/ post etc.
including but not limited to promotional communications. I confirm that I shall not challenge receipt of such communications by me as unsolicited communication,
defined under TRAI Regulations on Unsolicited Commercial Communications. I understand that I can at any time opt not to receive any telecommunication by registering
under the Do Not Call Registry.

13. I agree that this declaration shall be the basis of the decision by insurer to cover or not cover me under insurance.

14. I hereby authorize BFL to verify/check/obtain/download/ my KYC details available with CERSAI/UIDAI/CKYC registry. I agree that the details/documents provided by me
may be shared by BFL with the insurer(s) and may be downloaded/verified by insurer(s) for processing of this application. In the event if I am found to be existing
customer of BFL, I confirm that there is no change in my existing KYC details and authorize BFL to use my existing KYC for this application.

CANCELLATION/ TERMINATION

Consent Details : Accepted IP Address : 2409:4070:4209:21f2::14f1:40b0 Language Name : English Application Number : B2C000131932767 Date & Time : 2025-06-17 16:14:21 Mobile Number : 9014373552 Email ID :

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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 medical underwriting criteria.

STATUTORY WARNING (PROHIBITION OF REBATES) - SECTION 41 OF INSURANCE ACT 1938

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 maybe allowed in accordance with the published prospectus or tables of
the insurer.

2. Any person making any default in complying with the provisions of this section shall be punishable with fine which may extend to Ten Lakh Rupees.

Fraud, misrepresentation and forfeiture: Fraud, misrepresentation and forfeiture would be dealt with in accordance with provisions of Section 41 of the Insurance
Act 1938 as amended from time to time.

Disclaimer: - Conditions apply - These products are offered under the Group Insurance scheme wherein Bajaj Finance Limited is the Master policyholder. The insurance
coverage is provided by our partner Insurance Company, Bajaj Finance Limited does not underwrite the risk. IRDAI Corporate Agency Registration Number CA0101. BFL
does NOT hold any responsibility for the issuance, quality, serviceability, maintenance, and any claims post sale. Please refer insurer's website for Policy Wordings.
Purchase of this product is purely voluntary in nature. BFL does not compel any of its customers to mandatorily purchase any third party products.

I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc and voluntarily applying for HEALTH PLUS

I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc and voluntarily applying for BAJAJ ALLIANZ LIFE GROUP SAMPOORNA
JEEVAN SURAKSHA

B2C/PL/Insurance/Consent/V1

Consent Details : Accepted IP Address : 2409:4070:4209:21f2::14f1:40b0 Language Name : English Application Number : B2C000131932767 Date & Time : 2025-06-17 16:14:21 Mobile Number : 9014373552 Email ID :

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