PSRF633610022311 | CANA

MEMBER ENROLLMENT FORM – HDFC Life Group Credit Protect Plus

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

Options: Life Option Extra Life Terminal Life Critical Life Critical Life Critical Life Critical Life Life Disability
Option Option Option 1 Option 2 Option 3 Option 4 Option
Base Rider Premium Policy
Single Premium (`)
Sum Assured (`) Sum Assured (`) Payment Term (months) Term (months)
Life to be Assured

Master Policy Holder Name :_________________________________ Master Policy Holder Policy No:____________________ Applicant Status: Primary borrower Co Borrower Joint Life

% (for decreasing option) (additional form to be filled for joint life)

DD MM Y Y Y Y
Loan type:_________________ Loan disbursal date ________________ Loan amount _________________ Loan Account Number ____________________ Loan Term (months)

I/we understand that I/we have taken the Loan in name of _______________________________________(borrower), ___________________________________________________(co-borrower/s)
and declare that I/we are taking insurance cover for _______________(borrower), _________________________________ (co-borrower) as Single life/Joint Life (Strike out whichever not applicable)

Personal Details of Life to be Assured

Mr. Mrs. Ms. Dr.

Name F I R S T M I D D L E L A S T

Date of Birth: D D M M Y Y Y Y Gender: M F Transgender PAN:

Address for communication

City State Pincode

Nationality: Indian Non Indian Resident status: Resident NRI / PIO / OCI (If you are NRI/PIO/OCI / Student Studying Abroad please attach appropriate Questionnaire)
(For Students & Education Loan,
Country of Residence________________ Mobile No Email Id:_________________________
Country of study to be entered)
Education: Post Graduate Graduate| Diploma 12th pass 10th pass Below 10th Illiterate

Present Occupation: Salaried Self Employed Professional Armed/Police Agriculture Fire Service Retired Student Housewife Unemployed
Forces
(if you are working in the Navy / Police / Army/Air force / Fire Service, please attach appropriate questionnaire)

Gross Annual Income ( ):

Nominee / Appointee:

Full Name Date of Birth Relationship to Share (%)

Nominee 1: DD MM Y Y Y Y Life to be Assured

Nominee 2: DD MM Y Y Y Y Life to be 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 Y Gender: M F Transgender Relationship with Life to be Assured ____________________

Life to be Assured

1. Yes No
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 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 (g) Diabetes, high blood pressure (h) Any Other disorders.
2. During the last 5 years have you undergone any major surgery or been hospitalized for more than one week? Yes No
3. Do you take part in any adventurous sports or hobbies? (like paragliding, mountaineering, deep sea diving , motor racing, bungee jumping, etc.) Yes No
4. Do you currently smoke more than 10 cigarettes/bidis per day or chew more than 5 pouches of tobacco per day and/or consume alcohol more than 5 units a day?
Yes No
(5 Units = 400 ml Wine or 150 ml Spirits or 370 ml Beer)
5. 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? Yes No
6. 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)? Yes No
7. For Female Lives: (a) Are you presently pregnant? (b) Do you have a history in the past of an abortion, miscarriage or caesarian section due to complications during pregnancy or due Yes No
to any other cause? (c) Have you given birth to a child with any congenital disorder such as Down Syndrome, congenital heart disease, etc? (d) Have you ever had any disease of
breast, uterus, cervix, ovaries or any other part of the reproductive system?
8. Have you ever been declined, deferred, and accepted at special terms, had cover reduced or had exclusion imposed for any insurance cover? Yes No
9. Yes No
court of law in India or abroad?
10. 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/ Yes No
handling heavy machinery etc.)
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?
Yes No
If yes, please specify sum assured. Rs. ___________________________

For queries or more information, call us on 1860-267-9999 (Local charges apply) | 022-68446530
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com UIN: 101N096V03
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 Declaration of Life to be Assured
e 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.
ny additional provisions that govern the policy to be issued by insurer in the

•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 th
thereof.
8 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
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 sign
•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
urance company to which an application for insurance has been made
for the purpose of underwriting the proposal and /or claim settlement.

Signature/Thumb impression: __________________ Signature/Thumb impression: _______________________

(Life to be Assured) (Witness)
DD/MM/YYYY
Date:____________ DD/MM/YYYY
Date:____________

Place:___________ Place:___________

Declaration made by Declarant where Life to be Assured has;

“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
the contents thereof.”
Name of the Declarant___________________________ Name of the Witness___________________________

Address of the Declarant_________________________ __________________________ Address of the Witness__________________________ __________________________

Signature/Thumb impression Signature/Thumb impression
DD/MM/YYYY
Date:_________________ Place:_________________ DD/MM/YYYY
Date:_________________ Place:_________________
(Declarant) (Witness)
“I certify that the contents of the form and documents have been fully explained to me by Mr. / Mrs.:________________________ a

__________________________ Date:____________
DD/MM/YYYY Place:___________
Signature/Thumb impression
(Life to be Assured)
Declaration made by Legal Guardian where Life to be Assured is a minor: I hereby declare that the content of the form and docum

Name of the Witness___________________________

Legal Guardian
(if Life to be Assured is a Minor) __________________________
__________________________ Address of the Witness__________________________
Signature/Thumb impression
Signature/Thumb impression
DD/MM/YYYY
Date:_________________ Place:_________________ (Witness)

PAYMENT AUTHORISATION(For Non Regulated entity this authorization is not required)

I do hereby declare that I have received a loan from M/s ______________________________________________________ (“Master Policyholder”). In order to secure the said
loan I have taken the above referenced policy from HDFC Life Insurance Company Limited (“HDFC Life”). In consideration of receiving the said loan I hereby authorize HDFC 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: __________________ Signature/Thumb impression: __________________
DD/MM/YYYY
Date:____________ (Life to be Assured) DD/MM/YYYY
Date:____________ (Witness)
Place:___________ Place:___________

Questionnaire for COVID-19* *Novel Coronavirus, SARSCoV-2/COVID-19

Life to be Assured
1. Have you travelled outside India in the last 15 days or do you plan to travel overseas during next NO YES If YES, please provide details
3 months?
Country: _____________________________________________
City: ________________________________________________
dd/mm/yyyy
Date of travel: ________________________________________

2. Within the last 3 months have you been tested positive for COVID-19* and were hospitalised or NO YES If YES, please provide details
waiting results of such a test or been advised to be under hospitalisation or quarantine due to dd/mm/yyyy
1. Date of diagnosis test ________________________
COVID-19*?
2. Were you hospitalised? NO YES
3. Provide date of negative test report or hospital discharge date or last day of quarantine
dd/mm/yyyy
whichever is later _____________________________________
4. Details of subsequent tests done post hospitalisation/ quarantine during recovery like
RTPCR, CXR, HRCT, Ddimer etc__________________
Please provide copies of hospitalization reports, Discharge Summary, investigation
reports like RTPCR, CXR, HRCT, Didimer etc
5. Have you made a full recovery to good health without complications and returned to
normal physical function and activities?
NO YES

3. In the last 1 month have you been self-isolated or advised to self-isolate due to COVID-19* (excluding NO YES
mandatory government orders to at home) or have you had a persistent cough,fever, raised

tested positive, advised to be tested or are awaiting test result for COVID-19* or been in contact with an

Signature/Thumb impression: _____________________ DD MM Y Y Y Y

Date:___________________ Place:___________________

HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off:
For queries or more information, call us on 1860-267-9999 (Local charges apply) | 022-68446530
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com UIN: 101N096V03
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