Digitally Signed by: Shammi Kapoor

Date: 27/05/2025
Location: Mumbai

Transcript of the Proposal Form

Proposal No. PPR/BT/28554/7030223190 URN No. AH/2024-25/HL-14 Intermediary Code 0029302005

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) Rajdeep Banesinhbhai Dodiya

Date Of Birth 15/08/1994 Gender MALE

(DD/MM/YYYY)

Unique Govt. ID No. -

PAN Card No. -

Annual Income (in lakhs)

Occupation Salaried

Marital Status Single

E-Mail ID rajdodia216@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

Mobile 9727191969 Alternate Mobile -

Residential Address In 331, mafat plotvistar, kodinar,panch ,pipalva, gir somnath ,gujarat
India^

Landmark - Area -

City/Town JUNAGADH Pin Code 362720

District - State GUJARAT

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: TATHLIP26052V052526

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 Permanent Address If same as Residential Address in India, please tick here

331, mafat plotvistar, kodinar,panch ,pipalva, gir somnath ,gujarat

Landmark - Area -

City/Town JUNAGADH Pin Code 362720

District - State GUJARAT

^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.

TATA Group Employee

2. Plan Details:

Proposed Policy Commencement Date(DD/MM/YYYY): 27/05/2025 To 26/05/2026

Policy Tenure: 1 year 2 Year (5% premium discount) 3 Year (7.5% Premium Discount)
Sum insured type: Floater Individual
No Claim Bonus: Cumulative Bonus Discount in Renewal Premium (No Claim Bonus)
You will have an option to choose Cumulative Bonus or Discount in Renewal Premium (No Claim Bonus) at the time of renewal of
the Policy.

Rider Cover for TATA AIG MediCare Premier UIN TATHLIP26052V052526

Package Name Rider Names Cover/Benefit Name Coverage Limit
Cumulative Bonus Shield Flexi Shield UIN: TATHLIA25039V012425 Cumulative Bonus Shield RS 50000
Restore Infinity Plus Flexi Shield UIN: TATHLIA25039V012425 Restore Infinity Plus Applicable
Inflation Protect Flexi Shield UIN: TATHLIA25039V012425 Inflation Protect Available

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: TATHLIP26052V052526

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

Insured Person's
Insured 1
Name

Name of the
Proposed Insured Rajdeep Banesinhbhai Dodiya
Person

Gender M

Relationship with
Self
the Proposer*

Date of Birth 15/08/1994

Height (Cms) 175

Weight (Kgs) 70

Sum Insured (₹) # 1000000

ABHA Number (14

digits)^^

*Allowed relations.
Family Floater: Self, Spouse (Same or opposite gender), Dependent Children, Parents/Parents-in-law.
Individual: Self, Spouse/ Partners, Dependent Children, Parents/Parents-in-law, Grandparents, Grandchildren, Siblings (Sister/Brother), Uncle, Aunt, Nephew, Niece, Employee, Domestic
Help, Legal Guardian

For coverage of the below mentioned relationships, submit the listed documents:

Relationship Documents to be submitted

Employee Employment letter

Domestic Help Declaration Form for Domestic Help Coverage

Legal Guardian Legal guardianship certificate

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

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.

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: TATHLIP26052V052526

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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.

Details/Particulars Nominee 1

Date of Birth* 29/12/1996

Relationship Brother

Present Address of
the Nominee

Permanent Address If same as Present Address: true

of the Nominee

Mobile

Email ID

Percentage Share for

Claim Amount 100
Payable

Bank Details of the Nominee:

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: TATHLIP26052V052526

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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
Decline Disease Name N
Have you or any of the persons proposed for insurance, ever suffered from or 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 Y
or for minor injuries that have completely healed?
Are you or any persons proposed on regular medication (including any Ayurvedic 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
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
delivery (EDD). Any history of pregnancy related complications?
Has any application for life, Health or critical illness insurance ever been declined, 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
Have you ever been diagnosed with any Thyroid Disorder with or without any N
follow-up tests/medications?
Do you have any signs, symptoms, illness or injury including knee joint ligament 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
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.)

Insured Name Name of Date of Medication Mode of Progress Complications(S)

Disease(Medical) diagnosis history medication

Rajdeep Banesinhbhai Dodiya juvenile 01/09/2010 Regular Oral Controlled No

angiofibroma)

C. Lifestyle Information
Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes No

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: TATHLIP26052V052526

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7. Payment Details:

Name of the Premium Payer:

(If different from proposer)
Relationship with the Proposer:
(If different from proposer)
Premium Amount (in ₹): 12749

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: Rajdeep Banesinhbhai Date: 27/05/2025

Dodiya

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: TATHLIP26052V052526

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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) -

Please fill an auto debit form for deduction of amount towards premium payment from bank account.
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.
Ayushman Bharat Health Account (ABHA) Declaration: I on behalf of all Proposed Insured Person(s) provide consent to
access the medical and personal records/details [of all Proposed 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.
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.
Signature of Proposer: Rajdeep Banesinhbhai Date: 27/05/2025
Dodiya

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: TATHLIP26052V052526

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 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: Rajdeep Banesinhbhai Dodiya
Name & Signature of Agent/Intermediary with Code: girnar insurance brokers private limited & 0029302005

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: Rajdeep Banesinhbhai Dodiya
Name & Signature of Agent/Intermediary: girnar insurance brokers private limited & 0029302005

Disability Declaration:
(Note: The below must be witnessed by someone other than the Advisor/Employee of the Company)

I certify that the replies in the Proposal Form have been recorded as per the information provided by me. I, (Full name of the
representative) - (Relationship with the Proposer) - ,adult and inhabitant of (City) - residing at - do hereby certify that I have read
out and explained the contents of the Proposal Form and all other documents incidental to availing the Insurance Policy from
TATA AIG General Insurance Company Ltd., to the Proposer and they have understood the same. I declare that the facts stated
herein are true and correct to the best of my knowledge and belief.
Signature of the Authorised Person: -

11. Agent Declaration:

I,girnar insurance brokers private limited 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) : 588

Name of the specified Person and code : girnar insurance brokers private limited & 0029302005

Place: GURGAON Date : 27/05/2025 Signature of Agent : girnar insurance brokers private 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 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: TATHLIP26052V052526

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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.
Section 64 VB of Insurance Act:
Commencement of the risk cover under the Policy is subject to receipt of Premium by TATA AIG General Insurance Company
Limited.

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: TATHLIP26052V052526

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

Proposal No. PPR/BT/28554/7030223190 Date 27/05/2025

Name of the Proposer Rajdeep Banesinhbhai Dodiya

We acknowledge with thanks the receipt of your Proposal for TATA AIG MediCare Premier and amount by
cheque/Demand Draft/others of amount of ₹ . 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.

TATA AIG General Insurance Company Limited

Disclaimer: Insurance is the subject matter of the solicitation. For more details on benefits, exclusions, limitations, terms & conditions, please read the Policy Wordings carefully, before concluding a sale. Trade
logo displayed above belongs to Tata Sons Private Limited and AIG and used by TATA AIG General Insurance Company Limited under License.

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: TATHLIP26052V052526

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