Digitally Signed by: Shammi Kapoor

Date: 16/04/2025
Location: Mumbai

Transcript of the Proposal Form

Proposal No. PPR/BT/28554/7030173999 URN No. AH/2024-25/HL-02 Intermediary Code 2259450000

This is an application for insurance and issuance of this does not amount to acceptance of proposal by us. Commencement of risk
under this proposal is subject to acceptance of the risk by us and receipt of premium.
The information declared by you in this form is the basis for issuance of the policy. Please answer all questions carefully. Any
incomplete, incorrect or partially correct answers may lead to rejection of the proposal and also might lead to cancellation of
policy.

Please fill-up this form in CAPITAL LETTERS

1. Proposer’s Details:

Name (Mr/Mrs/Ms/Dr) Ashutosh Narain

Date Of Birth 15/09/1980 Gender MALE

(DD/MM/YYYY)

Unique Govt. ID No. AEBPN5546D Mobile No. 8826984000

Occupation -

Annual Income (in lakhs)

E-Mail ID ASHUTOSHNARAIN@GMAIL.COM

i. Is Nationality or Residence Status of either the Proposer or any of the Insured Person(s) is ‘other than Indian’ (i.e. the Nationality
or Residence Status is Non Resident Indians (NRI)/ Overseas Citizen of India (OCI)/ Foreign Nationals)? Yes No
ii. If you are Resident Indian National and want to opt out of Global Cover for Planned Hospitalization Yes No
*If the answer to (i) or (ii) above is ‘Yes’, you are eligible for a premium discount and ‘Global Cover for Planned Hospitalization’ as a Benefit is not available under this policy and no claim
shall be admissible under this section.

Nationality Indian Foreign Nationals

Residential Address In C-63 SEC-33 NOIDA

India

Landmark - Area -

City/Town GAUTAM BUDDHA NAGAR Pin Code 201301

District - State UTTAR PRADESH

PAN Card: AEBPN5546D

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 1 of 10
^Important Note:
Here ‘Address’ implies the place where the person ordinarily resides. In case proposed Insured Person(s) reside at multiple addresses, then address of the person residing in the
highest zone to be provided.
Zone definitions as mentioned in the prospectus (wherein Zone A is highest followed by Zone B and Zone C respectively.
Declared ‘Address’ will form the basis for the calculation of the premium.
Address’ is a material fact for calculation of the premium. "Material facts" for the purpose of this Policy shall mean all relevant information sought by the company in the proposal
form and other connected documents to enable it to take informed decision in the context of underwriting the risk.
Any misrepresentation or misdescription of the same by the policyholder may lead to termination of the policy as per policy terms and conditions and accordingly all premium paid
thereon shall be forfeited to the Company.

Note 2:
In case of Non Resident Indians (NRI)/ Overseas Citizen of India (OCI)/ Foreign Nationals) customers, Zone A premium shall be
applicable, irrespective of residential address in India.

TATA Group Employee

2. Plan Details:

Proposed Policy Period: 18/04/2025 To 17/04/2026

Policy Tenure: 1 Year 2 Years (5% premium discount) 3 Years (10% premium discount)
Sum insured type: Floater Individual

Rider Cover for TATA AIG MediCare Premier UIN TATHLIP24159V042324

Package
Rider Names Cover/Benefit Name Coverage Limit
Name
Mental Mental Wellbeing UIN: Mental Health Screening Once every policy year for listed tests, only on
Wellbeing TATHLIA25037V012425 Cashless basis
Psychological Therapy and Maximum Upto 10 sessions per person in a policy
Procedures year, only on Cashless basis
Diet Consultation Rider Maximum Upto 4 sessions per person in a policy
year, only on Cashless basis
Vocational Rehabilitation Up to base Sum Insured, Over and above the base
Sum Insured, Maximum upto 30 days
Stress Management Rider Available
Addiction Cessation Program Available
Accident Flexi Shield UIN: Additional Sum Insured for Up to Base Sum Insured, once in a policy year, Over
Suraksha TATHLIA25039V012425 Accidental Hospitalization and above the base Sum Insured
Permanent Total Disability Rs 1500000
Benefit Rider
Restore Flexi Shield UIN: Restore Infinity Plus Applicable
Infinity TATHLIA25039V012425
Plus
Inflation Flexi Shield UIN: Inflation Protect Available
Protect TATHLIA25039V012425

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 2 of 10
3. Details of the Person(s) to be Insured:

Relationship
Sr. Name of the Insured Date of Sum ABHA Number (14
Gender with the Height Weight
No. Person Birth Insured digits)
Proposer*

1 Ashutosh Narain M Self 15/09/1980 172 102 -

2 Charu Tak F Spouse 11/10/1983 157 57 1500000 -

3 Prathmesh Narain M Son 1 06/11/2022 91 16 -

*Allowed relations (Spouse, children and dependent parents/parents in law).

#Sum Insured options available ₹ (5, 10, 15, 20, 25, 50, 75, 100, 200, 300 Lakhs); Same Sum Insured for all members in floater option

^^Ayushman Bharat Health Account (ABHA) Number.

Ayushman Bharat Health Account (ABHA) Declaration: I on behalf of all Insured Person(s) provide consent to access the
medical and personal records/details [of all Insured Person(s)], as are available in my/our Ayushman Bharat Health Account (ABHA)
and share the same with Third Party Administrators, Reinsurer (if applicable), Service Provider(s) of TATA AIG General Insurance
Company Ltd and/or with any Governmental and/or Regulatory authority for the sole purposes of underwriting my/our Proposal
and/or for checking the authenticity of claims lodged by me/us and/or to comply with the applicable Law/Regulations.
Note: If ABHA Number is not available, we urge you to visit https:abdm.gov.in for creation of ABHA ID and infom the same to us
once created.

4. Nominee Details:
In the event of the death of the proposer any payment due under the policy shall become payable to the nominee in accordance
with the policy Terms and Conditions.

Nominee Name Date of Birth* Relationship Address of the Nominee

CHARU TAK 11/10/1983 Wife -

5. Existing/Previous Insurer Details:

Is the proposer or any of the persons proposed, already Insured under a health plan with TATA AIG General Insurance Company
Ltd. or any other insurer or is a proposal pending for policy issuance? If yes, please indicate the Policy/Application number(s):

Since when continuously insured :

Do you want Us to consider these details for portability*? Yes No

*Please note that continuity of benefits shall NOT be considered if the details are not provided. You need to approach us at least 45 days prior to your expiry date to avoid any break in
coverage. Please submit all previous year insurance policy copies.

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 3 of 10
 Claims lodged
Period of Insurance Sum
during the
Name of Insured Insured &
Policy No. Insurer preceding years
person Cumulative
From To along with the
bonus (₹)
diagnosis

2856206349130300000 Ashutosh Narain HDFC ERGO 18/04/2024 17/04/2025 No

GENERAL
1500000
INSURANCE
CO.LTD.

360200502210008019 Ashutosh Narain NATIONAL 31/03/2023 30/03/2024 No

INSURANCE 1000000
CO.LTD.

360500502110003046 Ashutosh Narain NATIONAL 31/03/2022 30/03/2023 No

INSURANCE 1000000
CO.LTD.

360500502010003467 Ashutosh Narain NATIONAL 31/03/2021 30/03/2022 No

INSURANCE 1000000
CO.LTD.

2856206349130300000 Charu Tak HDFC ERGO 18/04/2024 17/04/2025 No

GENERAL
1500000
INSURANCE
CO.LTD.

360200502210008019 Charu Tak NATIONAL 31/03/2023 30/03/2024 No

INSURANCE 1000000
CO.LTD.

360500502110003046 Charu Tak NATIONAL 31/03/2022 30/03/2023 No

INSURANCE 1000000
CO.LTD.

360500502010003467 Charu Tak NATIONAL 31/03/2021 30/03/2022 No

INSURANCE 1000000
CO.LTD.

2856206349130300000 Prathmesh Narain HDFC ERGO 18/04/2024 17/04/2025 No

GENERAL
1500000
INSURANCE
CO.LTD.

360200502210008019 Prathmesh Narain NATIONAL 31/03/2023 30/03/2024 No

INSURANCE 1000000
CO.LTD.

360500502110003046 Prathmesh Narain NATIONAL 31/03/2022 30/03/2023 No

INSURANCE 1000000
CO.LTD.

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 4 of 10
 Claims lodged
Period of Insurance Sum
during the
Name of Insured Insured &
Policy No. Insurer preceding years
person Cumulative
From To along with the
bonus (₹)
diagnosis

360500502010003467 Prathmesh Narain NATIONAL 31/03/2021 30/03/2022 No

INSURANCE 1000000
CO.LTD.

6. Medical And Lifestyle Details:

A. Medical History:
Please answer the below mentioned questions individually in Yes (Y) / No (N):
You must answer the questions truthfully. Not doing so would lead to termination of your policy.
Please answer each of the following questions individually for each Insured Person
Insured Persons
by ticking the relevant box.
1 2 3
Decline Disease Name N N N
Have you or any of the persons proposed for insurance, ever suffered from or N N N
taken treatment, or hospitalized for or have been recommended to take
investigations / medication / surgery or undergone a surgery for medical
conditions specified on Proposal form?
Any other illness/disease/injury/disability in the past other than for childbirth, flu N N N
or for minor injuries that have completely healed?
Are you or any persons proposed on regular medication (including any Ayurvedic N N N
treatment) or Hospitalized for any illness/ surgery or awaiting any
procedure/treatment?
Have you ever been diagnosed with any of these medical conditions with or N N N
without any follow-up tests/medications? – Elevated Blood Sugar/ Type 2 Diabetes
Mellitus/ Elevated Blood Pressure/ Hypertension/High Cholesterol/ Asthma>>
Is any of the insured pregnant currently? If yes, please mention expected date of N N N
delivery (EDD). Any history of pregnancy related complications?
Has any application for life, Health or critical illness insurance ever been declined, N N N
postponed, loaded or been made subject to any special conditions by any
insurance company?
Has any health or life insurance policy ever been terminated in the past ? N N N
Have you ever been diagnosed with any Thyroid Disorder with or without any Y N N
follow-up tests/medications?
Do you have any signs, symptoms, illness or injury including knee joint ligament N N N
tear or back pain/ Swelling or Pain in any part of body / Breathlessness on mild
effort / dizziness more than once in last 6 months for which medical consultation /
treatment / investigation has been required ?
Have you undergone any annual health check-up or routine medical examination N N N
in the past year? (If yes, please provide details of any findings or results)?

B. Detailed information in case any of the questions in section (A) is ticked ‘Yes’.
(Please send us medical documents along with this application form.)

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 5 of 10
 Insured Name Name of Date of Medication Mode of Progress Complications(S)
Disease(Medical) diagnosis history medication

Ashutosh Narain Hypothyroid 08/08/2022 Regular Oral Controlled No

C. Lifestyle Information
Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes No
If yes please indicate the name and quantity per day.

Insured Persons

1 2 3

Alcohol (in ml) 30 ml - Hard Liquor / Weekly - 3 Years

Per Day
Per Week
Per Month
Occasionally

Smoking (No of Cigarettes or 2 Weekly - 3 Years

Bidis/day)
Per Day
Per Week
Per Month
Occasionally
Pan Masala/Tobacco (in gms)
Per Day
Per Week
Per Month
Occasionally

Other habit forming

substances/addictive (Quantity
Consumed)
Per Day
Per Week
Per Month
Occasionally

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 6 of 10
7. Payment Details:

Name of the Premium Payer:

(If different from proposer)
Relationship with the Proposer:
(If different from proposer)
Premium Amount (in ₹): 40939

Instrument type: Cash Cheque Debit Card Credit Card Others

Please make a Crossed Cheque/DD/Pay Order in favour of ‘TATA AIG General Insurance Company Limited’ only
Sources of funds: Salary Business Others

AML Guidelines:
1. I/We hereby confirm that all premiums paid/payable in future will be from bonafide sources and not paid out of proceeds
of crime and that such premiums are not disproportionate to my/our income. I/we understand that the Company has the
right to call for documents to establish sources of funds and to cancel the Insurance Policy in case I/we are found guilty by
any competent court of law under any of the statutes, directly or indirectly governing the prevention of money laundering
law in India.
2. I/We are not Politically Exposed Persons ** nor are their close relatives/family members/associates. I/We shall keep the
company informed if we subsequently become a Politically Exposed Person(s).
**“Politically Exposed Persons” shall have the meaning assigned to it under Prevention of Money-Laundering
(Maintenance of Records) Amendment Rules, 2023 as amended from time to time.

Type of Organization Making the Payment (Please Tick):

Limited Company Government Organization Non-Governmental Organization (NGO)
Society Trust Partnership
International Organization Cooperatives Section 25 Company

Signature of Proposer: Ashutosh Narain Date: 16/04/2025

8. Bank Details (Required For Refund/Claims):

As per Regulatory requirements, we can effect payment of refund/claims only through Electronic Clearing System (ECS)/ National
Electronics Funds Transfer (NEFT)/Real Time Gross Settlement (RGTS)/Interbank Mobile Payment Service (IMPS).
For this purpose, please submit the following details of the proposer’s bank account.

Name of the Account Holder -

Name of the Bank

Branch Bank -

Account No.

Bank IFSC Code

Account Type SB Account Current Account Others(please specify) -

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 7 of 10
9. Declaration & Warranty on Behalf of all Persons Proposed to be Insured:

• 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 the insurance policy, is subject to the Board
approved underwriting policy of the insurer and that the policy will come into force only after full payment of the premium
chargeable.
• I further declare that I 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time 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 authorize the company to share information pertaining to my 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.
Signature of Proposer: Ashutosh Narain Date: 16/04/2025

I understand that I will receive digital copy of my Policy and service-related communication. However, I would prefer to also
receive the physical copy of my Policy and service-related communication and I want these documents to be shared via postal mail
to the address as mentioned in this Proposal Form.

10. Declaration/Vernacular Declaration:

The content of this form along with product benefits, Terms and Conditions and exclusions have been clearly explained to me.
I/We have understood these and confirm to abide by the policy Terms and Conditions.
Signature of Proposer: Ashutosh Narain
Name & Signature of Agent/Intermediary with Code: reshmi kumari & 2259450000

Vernacular Declaration (Certification in case the proposer has signed in Vernacular/Thumb print).
The content of this form along with product benefits, Terms and 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: Ashutosh Narain
Name & Signature of Agent/Intermediary: reshmi kumari & 2259450000

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 8 of 10
11. Agent Declaration:
I,reshmi kumari in my capacity as an Insurance Advisor/Specified Person of the Corporate Agent/Authorized 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 favor
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.

License No.(Intermediary/Corporate Agent/Broker/Relationship Officer) : AGINAUZPK3406B

Name of the specified Person and code : reshmi kumari & 2259450000

Place: MOTI NAGAR Date : 16/04/2025 Signature of Agent : reshmi kumari

12. Section 41 of Insurance Act 1938 (Prohibition of Rebates) as amended by Insurance Laws (Amendment) Act, 2015

• 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.
• 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.
13. For Office Use Only

TATA AIG Office Code Intermediary Code and Name

Branch Receipt Date Channel Type

Business Type Customer ID

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 9 of 10
 14. Acknowledgement (To Be Given To Customer)

Proposal No. PPR/BT/28554/7030173999 Date 16/04/2025

Name of the Proposer Ashutosh Narain

We acknowledge with thanks the receipt of your Proposal for TATA AIG MediCare Premier and amount by
cheque/Demand Draft/others of amount of ₹ 40939 . Neither the submission to us of a completed Proposal 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 you do not accept the
terms of counter offer or premium is not received by us in full and in time, or non fulfilments of Pre-Policy Check-up
and/or additional information requested by us. 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. In case
of counter offer you need to revert to us with consent and additional premium (if any), within 15 days of the issuance of
such Counter Offer Letter. In case, you neither accept the counter offer nor revert to us within 15 days, we shall cancel
application and refund the amount paid against this Proposal without interest subject to deduction of the Pre-Policy
Check up charges, as applicable. If we do not accept the Proposal, we will inform you and refund any payment received
from you without interest within next 10 days subject to deduction of the Pre-Policy Check-up charges, as applicable.

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 or 1800 22 9966 (For Senior Citizens) • Email: customersupport@tataaig.com • Website: www.tataaig.com
IRDA of India Registration No: 108 • CIN: U85110MH2000PLC128425 • TATA AIG MediCare Premier • UIN: TATHLIP24159V042324

Page 10 of 10