AFFIDAVIT CUM UNDERTAKING

I/WE ..................................... AGED ........

S/O, D/O. W/O............................................

RESIDING AT...........................................

DEPONENT DO HEREBY SOLEMNY AFFRIM AND DECLARE

1. THAT I/WE HAVE BEEN SANCTIONED A LOAN OF RS............................../-(IN

WORDS...................) BY HINDUJA HOUSING FINANCE LMITED (HHFL)
(LOAN) FOR LOAN AGAINST PROPERTY (EUITABLE MORTGAGE)/
CONSTRUCTION / PRUCHASE / IMROVEMENT/ RENOVATION /
EXTENSION OF HOUSE/ FLAT, OR TRANSFER OF AN EXISTING HOUSING
LOAN IN FAVOUR OF HHFL, COMPOSITE LOAN FOR PLOT &
CONSTRUCTION OF HOUSE SITUATED AT............................................................
2. THAT I/WE HAVE PROVIDE .................................................... AS SECURITY TO
THE LOAN
3. THAT I/WE MORTGAGOR HAS EXCLUSIVELY OWNERSHIP & POSSESSION
OVER THE RELEVENT PROPERTY .
4. THAT I/WE MORTGAGOR HAVE NEITHER CREATED RIGHT/CHARGE ON
THE PROPERTY IN QUESTION NOR TRANSFERRED IT OTHERWISE FULLY
OR PARTLY.
5. THAT RELEVENT PROPERTY DOES NOT UNDER ANY LIABILITY OF
GOVERNMENT DUES OR DEMAND ON THE RELEVENT PROPERTY.
6. THAT RELEVENT PROPERTY IS FREE FROM ALL ENCUMBRANCES AND
NOT ANY LEGAL LITIGATION PENDING REGARDING ANY TITLE OF THE
PROPERTY BEFORE ANY COMPETENT AUTHORITY/ COMPETENT CIVIL
COURT/ HIGH COURT/ SUPREME COURT OF INDIA AND THERE IS NOT
ANY VIOLATION OF LAW WITH REGARDS TO PROPERTY TO PROPERTY
IN QUESTION.
7. THAT I/WE HEREBY JOINTLY AND SEVERALLY AGREE AND DECLARE
THAT IF ANY TERMS AND CONDITIONS O0F THE LOAN AGREEMENT OR
ANY OF THE AVERMENTS MADE BY ME/US IN THIS AFFIDAVIT OR ANY
OTHER DOCUMENT IS FALSE, OR IS MISREORESENTED THEN HHFL HAS
THE RIGHT TO RECALL THE ENTIRE LOAN WITH INTEREST, COSTS AND
OTHER CHARGES AS HHFL DEEMS FIT.
8. THAT I/WE HEREBY SWEAR THAT MY/OUR DECLARTION AS SET OUT
ABOVE IS TRUE AND CORRECT AND THAT IT CONCEALS NOTHING AND
THAT NO PART HEREIN IS FALSE.
 9. THAT I/WE FURTHER UNDERTAKES THAT IN CONSIDERTION OF THE
LOAN ADVANCED SANCTION BY HHFL, I/WE SHALL INDEMNIFY AND
KEEP HHFL INDEMNIFIED AT ALL TIMES FOR ANY LOSS AND DEMAGES
CAUSED TO HHFL ON ACCOUNT OF ANY ACT DONE OR CAUSEDE TO BE
DONE BY THE ME/US.

PLACE.................................

1. SIGNATURE:

NAME:

DATE:

2. SIGNATURE:

NAME:

DATE:

VERIFICATION

I/WE HAVE VERIFIED AT ......................ON...................DAY OF ...................... MONTH

THAT THE CONTENTS OF THE ABOVE AFFIDAVIT ARE TRUE TO MY
KNOWLEDGE AND BELIEF AND NOTHIG MATERIALS HAS BEEN CONCEALED
THEREFROM.

PLACE.................................

1. SIGNATURE:

NAME:

DATE:

2. SIGNATURE:

NAME:

DATE:
MEMBER CONSENT/DECLARATION FORM

Plan ICICI Pru Group Loan Secure Life Option Accidental Death Benefit Critical Illness

Sum Assured (INR) Premium (INR) Annual One time pay Other Policy Term (yrs)

Particulars of Life Assured Mr/Mrs :

Address :

Date of Birth/Age(yrs) : d d m m y y y y / Gender: M / F Loan Account No:

Loan Type: Mobile No: Email id :

*Receive communications through phone/email

Details Name Date of Birth Gender Contact No. Relationship to

Nominee dd/mm/yyyy M/F

Appointee dd/mm/yyyy M/F

*If Nominee is less than 18 yrs, Appointee is mandatory. Appointee should be more than 18 yrs of age.

Personal Details of the Life to be Assured - Detailed Medical Questionnaire

SUPPRESSING FACTS OR GIVING WRONG INFORMATION WILL ADVERSELY IMPACT PAYMENT OF YOUR CLAIM
1. Age Proof Passport Driving Licence School/ College Certificate Others Specify

a. Height (Ft/ Inches) cms b. Weight (Kilograms)

Is the answer to any of the below mentioned medical questions (Q.No.2 to 9) Yes? Yes No
2. Do you consume or have consumed any of the following?
i. Do you smoke more than 10 cigarettes/beedis a day? ii. Do you consume more than 60ml of alcohol in a day? iii. Do you consume any narcotics? iv. Do you chew more
than 30 gms of Tobacco (Gutka) per day?
3. Family details of the life to be assured (include parents/sibling) Are any of your family members suffering from/have suffered from/have died of heart disease, Diabetes
Mellitus, cancer, or any other hereditary/familial disorder, before 55 years of age? if yes please provide details here________________________________________________
4. Have you lost weight of 10 kgs or more in the last six months?
5. Do you have any congenital defect/abnormality/physical deformity/handicap?
6. Have you undergone or been advised to undergo any tests/investigations or any surgery or hospitalized for observation or treatment in past?
7. Did you have any ailment/injury/accident requiring treatment/medication for more than a week or have you availed leave for more than 5 days on medical grounds in
the last two years?
8. Have you ever suffered or been diagnosed with or been treated for any of the following?
Hypertension/High BP/high cholesterol Chest pain/Heart attack/any other heart disease or problem
Undergone angioplasty, bypass surgery, heart surgery Diabetes/High blood sugar/sugar in urine
Asthma, Tuberculosis or any other respiratory disorder Nervous disorders/stroke/paralysis/epilepsy
Any Gastro intestinal disorders like Pancreatitis, colitis etc. Liver disorders/Jaundice/Hepatitis B or C
Genitourinary disorders related to kidney, prostate, urinary system Cancer, Tumour, Growth or cyst of any kind
HIV infection/AIDS or positive test for HIV Any blood disorders like anaemia, Thalassemia etc
Psychiatric or mental disorders Any other disorder not mentioned above, please mention here______________________________
9. To be answered by female lives only
a. Have you ever suffered/are suffering from or have undergone any investigation or treatment for any gynecological complications such as, disorder of cervix, uterus,
ovaries, breast, breast lump/cyst etc.?
b. Are you pregnant at present? If yes, please mention number of weeks _________________
Payout Mode (Choose any one mode only)
Mode selected would be used by the company to make payout(s). Payout would be in accordance and subject to the terms and conditions of the policy. Cheque would be used if none of the below
Electronic Payout Option is chosen.

1. Mode of deposit ECS Direct Credit (Select Banks only) NEFT 2. Account Type Current Savings

3. Bank Name 4. Bank Branch

5. Account Number 6. MICR Code
7. IFSC Code
Note: 1. Please provide a cancelled copy of your cheque if any of the above payout option is selected. 2. In case of non credit to my bank account with/ without
assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete/ incorrect information, I would not hold ICICI Prudential __________________________________
Life Insurance Co. Ltd. responsible. 3. Further, the Company reserves the right to use any alternative payout option in spite of opting for Direct Credit option. Signature of Proposer

Payment Authorisation
I do hereby declare that I have received a loan from Hinduja Housing Finance Limited ( Master Policyholder ). In order to secure the said loan I have taken the above
referenced policy from ICICI Prudential Life Insurance Company Limited. In consideration of receiving the said loan I hereby authorize ICICI Prudential Life to make
payment of Outstanding Loan Balance amount to Master Policyholder by deducting from the claim proceeds payable on happening of the contingent event covered by
the Group Life Insurance Scheme/ Policy referenced above.

__________________________________ __________________________________
Signature/Thumb impression of Witness* Signature / Thumb Impression of the Insured Member
Comp/doc/Nov/2016/717

Name & Address :

Date & Place: d d m m y y y y / Occupation :

__________________________________
*Witness Signature, Address and Occupation is along with signature of Insured Member Signature/Thumb impression of life to be assured
Declaration to be made by a 3rd person where: a) The insured member has affixed his/her thumb impression; OR b) The insured member has signed in vernacular; OR c) The insured member has not
filled the application.
I hereby declare that I have explained the contents of this application form to the insured member in ____________language and have truthfully recorded the answers provided to me. I further declare that
the insured member has signed/affixed his/ her thumb impression in my presence.
Name and address of Declarant__________________ Signature of the Declarant
Declaration made by life to be assured: 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.

Declaration & Authorization

I/We declare that I/we have signed the form after understanding its contents and have furnished true and complete information without withholding any material information. I/We shall immediately notify
any change in information, subsequent to signing this form and before the receipt of the Certificate of Insurance. I/We understand that the terms and conditions including the benefits are in accordance to
applicable laws as amended from time to time. I/We authorize the Company to assess and verify the health status of the life/lives to be assured through medical examinations including HIV1/2 test. The
Company reserves the right to accept, decline or offer alternate terms on my/our proposal for Life/Health Insurance. I/we authorize the past and present employer(s)/business associates/medical
practitioner(s)/hospital and medical source/any insurer to provide records to the Company for assessing risk under this proposal and any time thereafter. I/We have understood the terms and conditions of
the Group insurance schemes Rules of Hinduja Housing Finance Limited offering Group Loan Secure product and I wish to be a member of the scheme. I, authorize the Group organizer Hinduja Housing
Finance Limited to take group insurance on my behalf. In case of fraud or misrepresentation by me/us, the policy shall be treated in accordance with Section 45 of the Insurance Act, 1938 as amended from
time to time. I/We authorize the Company to mail service communications to my email id as provided. I/We agree and authorize the Company to verify/share my/our documents/ other information
provided herein on confidential basis within ICICI group and/or with third party agencies or if sought by any public authority.
Date: d d m m y y y y Place: _________________________________________________
Signature/Thumb impression of Proposer / Life to be Assured
 ENROLMENT FORM FOR GROUP HEALTH

URN No.: URN No. AH/2018-19/HL-09

Partner Reference
Name of the Group Administrator No./Application No.
Customer ID/Account no. Intermediary code
This is an application for Insurance & will form the basis of the policy certificate that We may issue. Every information, this
application seeks is important & mandatory. Please read all questions and answer them carefully. You must provide complete
and correct information. Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy
certificate even if it is issued. We are under no obligation to accept any proposal for insurance. 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 under the
Policy if proposal is not accepted by us or premium is not received by Us in full and in time, or non-fulfillments of additional
information requested by us, if any or if the proposal is under-process & claim arises in the interim period before the decision
on the proposal is given by us.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company
Limited.
Please fill-up this form in CAPITAL LETTERS
Section I: Applicant Information
Name: First Name Middle Name Last Name
(Mr/Mrs/Ms)

Date of birth: ________ Gender: _______ Nationality: _________________ Mobile No.: ______Email Id: _______________
Occupation: Salaried Self-employed Others (please specify) _______________________________________
Address for communication: _______________________________________________________________________________
_____________________________________________________Landmark__________________________________________
District: ________ City: ________ State: ________ Pin code: ___________________________________
Unique id no. (Aadhaar no.) : ___________________________PAN (in case of premium > Rs.50, 000) ___________________

Group MediPrime

Part A: Plan Details:

Sum Insured (in Lacs) 3 5

Tenure (in Years) 1

Plan Type Individual Floater

Part B: Proposed Insured Persons details:

Name of the Relationship with Aadhaar

Sr.No Insured persons Applicant Date of birth Gender Occupation No.
1
2
3
4

Group MediPrime UIN: TATHLGP14004V011314 Page 1 of 4

Part C: Medical & Lifestyle Information:
Note: This section is applicable for all the persons to be insured

Yes/No
Medical Information
Have you or any of the persons proposed for insurance, ever suffered from or taken Yes/No
treatment, or hospitalized for or have been recommended to take investigations /
medication / surgery or undergone a surgery for any of the following medical
condition?
• Cancer/Kidney failure/Stroke/Heart disease/Paralysis
• Any disease of major organs including but not limited to brain, heart, kidney,
lungs, liver or any neurological disorder
• Any joint disorder including restriction in movement or any form of arthritis
Are you or any of the persons proposed for insurance in good health? Yes/No
Are you or any of the persons proposed for insurance undergoing/awaiting any Yes/No
treatment for any illness?

Part D Premium Paid for product (including taxes):___________________________________________

Section V: Nominee Details

Nominee Name _____________________________Relationship with the Applicant ___________________________________

Nominee Date of Birth________________________

In the event of the death of the Applicant any payment due under the Policy shall become payable to the nominee in
accordance with the Policy terms and conditions. Nominee for any of the persons proposed to be insured shall be the
Applicant. The nominee must be an immediate relative of the Applicant. The nominee for all other Insured Persons proposed to
be insured shall be the Applicant himself/herself.

Section VI: 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 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 payment 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 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 insurance
company 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 proposal including the medical records of the
insured/proposer for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental
and/or Regulatory Authority.

Signature of the Applicant: _____________ Date: ________________ Place: _______________

Group MediPrime UIN: TATHLGP14004V011314 Page 2 of 4

 The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we
have understood these and confirm to abide by the policy terms & conditions.
Signature of the Applicant: _________________________________________________________
Name & Signature of agent/intermediary/Specified Person: __________________________________
Code:

Vernacular Declaration (Certification in case the applicant has signed in vernacular/thumb print)
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in
vernacular to the applicant who has understood and confirmed the same.
Signature/Thumb impression of the Applicant: __________________________________________
Name & Signature of agent/intermediary/Specified Person: ___________________________________

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
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 may be allowed in accordance with the published
prospectuses or tables of the insurer.
2. 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.

For office use only:

Employee ID:
Partner ID:

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions please read policy
document carefully before concluding a sale.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel,
Mumbai 400013

24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Fax: 022 6693 8170
Email:[email protected] Website: www.tataaig.com IRDA of India Registration No: 108 CIN:
U85110MH2000PLC128425

Group MediPrime UIN: TATHLGP14004V011314 Page 3 of 4

CUSTOMER ACKNOWLEDGEMENT
Application Number: _______________________ Date: ______________________
Name of the Applicant_______________________________________________________________
We acknowledge with thanks the receipt of your application and amount by cash/cheque/Demand Draft/others
________________________________ of amount of Rs._______________________. Neither the submission to us of this
completed enrollment form 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
premium is not received by us in full and in time, or non-fulfillments of Pre-Policy Checkup (if applicable) and/or additional
information requested by us. Failure to deposit the entire premium or non-fulfillments of pre-policy check up (if applicable) or
furnish additional information requested by us within 15 days from the date of proposal, we shall cancel your application and
refund the premium paid without any interest subject to deduction of pre-policy charges (if applicable & conducted). If we do
not accept the proposal, we will inform you and refund any payment received from you, towards this application, without
interest within next 10 days.
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.

Group MediPrime UIN: TATHLGP14004V011314 Page 4 of 4

 Enrolment Form - Group Credit Secure Plus

Intermediary Code: Master Policy Reference No.

Loan A/C No.
This is an application for Insurance & will form the basis of the policy certificate that We may issue. Every information, this application seeks is important
& mandatory. Please read all questions and answer them carefully. You must provide complete and correct information. Incomplete/incorrect/partially
correct information may lead to cancellation of proposal and policy certificate even if it is issued. We are under no obligation to accept any proposal for
insurance. 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
under the Policy if proposal is not accepted by us or premium is not received by Us in full and in time, or non-fulfillments of additional information
requested by us, if any or if the proposal is under-process & claim arises in the interim period before the decision on the proposal is given by us.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
Please fill-up this form in CAPITAL LETTERS
1. PROPOSER'S INFORMATION

Name: First Name Middle Name Last Name

(Mr/Mrs/Ms)

Date of birth: D D M M Y Y Y Y Gender: M F Nationality:

Occupation: Salaried Self-employed Others (please specify)

Address for communication:

District: City: State: Pin code:

Enrolment Form- Group Credit Secure Plus UIN: TATHLGP18051V011718

Insured Property Address (only in case of cover for Standard Fire and Special perils) :

District: City: State: Pin code:

Tel (O): Mobile: Email Id:

Premium (including Taxes) Unique id no. (Aadhaar no.):

PAN (in case of premium > ` 50, 000) GSTIN No.

Loan amount: Type of Loan: Loan tenure:

Policy tenure (Years): 1 2 3 4 5 Sum insured (same as loan amount & max. upto `5 Crores):

Sum Insured Type#: Fixed Reducing

#
applicable only for coverage of critical illness and/or personal accident benefit
Optional Cover Details:
Cover Opted Limits

Do you want the co-applicant to be part of Group Credit Secure Plus? Yes No
Note: In case of co-applicants, sum insured would be apportioned equally among members
2. INSURED PERSON'S DETAILS

Sr.No Name of the Insured persons Relationship with Proposer Date of birth Occupation Gender Nationality Unique Id no.

3. NOMINEE DETAILS
I understand that this policy is assigned to the Bank/ financial/lending institutions.
Nominee Name Relationship with the Proposer
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 for any of the persons proposed to be insured shall be the Proposer. The nominee must be an immediate relative of the Proposer. The
nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself.

% %
 It is hereby declared and agreed, I/we declare and agree that upon any monies becoming payable under this Policy the same shall be paid by the
Company to the Bank/ financial/lending institutions and such part of any monies so paid as may relate to the interests of other parties insured hereunder shall
be received by the Bank/ financial/lending institutions as Agents for such other parties. That the receipts of the Bank/ financial/lending institutions shall be
complete discharge of the Company therefore and shall be binding on all the parties insured hereunder.

4. MEDICAL AND LIFESTYLE INFORMATION

Please answer the below mentioned questions in Yes (Y) / No (N).

Insured Persons

1 2 3 4
Have you or any of the persons proposed for insurance, ever
suffered from or taken treatment, or hospitalized for or have been
recommended to take investigations / medication / surgery or Yes No Yes No Yes No Yes No
undergone a surgery for any of the following critical
medical condition#?

Are you or any of the persons proposed for insurance in good health? Yes No Yes No Yes No Yes No

Are you or any of the persons proposed for insurance undergoing/ Yes No Yes No Yes No Yes No
awaiting any treatment for any illness?
# Critical medical condition would mean Cancer, End Stage Renal Failure, Multiple Sclerosis, Major Organ Transplant, Rheumatic heart disease, Coronary
Artery Bypass Graft, Stroke, Paralysis, Myocardial Infarction, Angina, Total Blindness, Creutzfeldt-jakob disease, Primary Pulmonary hypertension, Motor
Neuron Disease with Permanent Symptoms, Progressive Scleroderma, Brain Tumor, Lung/Liver Failure.

5. 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 insurance policy, is subject to the Board approved underwriting policy of the

Enrolment Form- Group Credit Secure Plus UIN: TATHLGP18051V011718

Insurance company and that the policy will come into force only after full payment 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 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 insurance company 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 proposal including the medical records of the insured/proposer for the sole
purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me.
I/we have understood these and confirm to abide by the policy terms & conditions.

Signature of the Proposer:

Name & Signature of Agent/intermediary/Specified Person:

Code:

Vernacular Declaration (Certification in case the Proposer has signed in vernacular/thumb print)

The content of this form along with product benefits, terms/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:

Name & Signature of Agent/intermediary/Specified Person:

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015
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 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 prospectus or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to ten lakh rupees.

For Office use only - Employee ID: Partner Reference ID

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions
please read policy document carefully before concluding a sale.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
Website: www.tataaig.com IRDA of India Registration No: 108 CIN:U85110MH2000PLC128425

% %

CUSTOMER ACKNOWLEDGEMENT
Application Number: _______________________ Date: ______________________
Name of the Proposer: ________________________________________________________________________________________________________________________________
We acknowledge with thanks the receipt of your application for Tata AIG Group Credit Secure Plus and amount by cash/cheque/Demand Draft/others
________________________________ of amount of Rs._______________________. Neither the submission to us of this completed enrollment form 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 premium is not
received by us in full and in time, or non-fulfillments of Pre-Policy Checkup (if applicable) and/or additional information requested by us. Failure to deposit the entire
premium or non-fulfillments of pre-policy check up (if applicable) or furnish additional information requested by us within 15 days from the date of proposal, we shall
cancel your application and refund the premium paid without any interest subject to deduction of pre-policy charges (if applicable & conducted). If we do not accept the
proposal, we will inform you and refund any payment received from you, towards this application, without interest within next 10 days.
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.