PROPOSAL FORM

URN No.: AH/2024-25/HL-01

Proposal No. : IDV002238876 Intermediary Code : 0007652002

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.
1. PROPOSER’S DETAILS
Name (Mr/Mrs/Ms/Dr): Sambit Basu
Date of Birth: 27/11/1991 Gender: MALE
Mobile: 7980115272 Unique Govt ID No: BHEPB6762Q
Annual Income (in ₹ Lakhs): E-Mail ID: [email protected]
Address^: 8 9 C Rabindra Pally C Block Durga Pur
Landmark: - Area: -
City/Town: BARDHAMAN Pin Code: 713201
District: - State: WEST BENGAL
Nationality: Indian Foreign National

^ : 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. However, this shall not be applicable if the proposer has opted for “Value
Plan”
‘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 TATA Group Employee ID: -

2. POLICY DETAILS
Proposed Policy Commencement Date: 24/01/2025
Policy Tenure: 1 Year 2 Years (5% premium discount) 3 Years (10% premium discount)
Floater Sum Insured (in ₹ Lacs): 5 7.5 10 15 20
Plan: Value Plan (For Zone A, B & C customers.) Geo Plan (For Zone B & C customers.)
Room Category (Only available for Geo Plan): Single Private Room Shared Accommodation
(Your Premium shall be based on choice of Room Type that You make at the time of Proposal.)

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 1 of 6
Optional Covers: The below mentioned Optional Covers can be selected at policy level only.
S. No. Benefits Yes (Y) / No (N)
Sum Insured (in ₹) Deductible Options (in ₹) on floater basis
5 Lacs 25000 50000

7.5 Lacs 35000 70000

1. Aggregate Deductible
10 Lacs 50000 100000

15 Lacs 75000 150000

20 Lacs 100000 200000

2. Voluntary Sub-Limits N
3. Emergency Air Ambulance Cover N
4. Accidental Death Benefit N
5. Restore Infinity Y
6. Consumables Benefit N
7. Preventive Annual Health Check-Up N
8. Advanced Cover N

Note:
i. Aggregate Deductible is an irrevocable cost sharing requirement under this policy which provides that We will not be liable for a
specified amount in case of hospitalization/s during the policy year i.e. We will pay only if aggregate admissible claim amount in respect
of hospitalization/s during the policy year exceeds the aggregate deductible as specified in the policy schedule. An Aggregate Deductible
does not reduce the Sum Insured.
ii. Insured children or Insured person less than 18 years of age as on Policy commencement date will not be covered under Accidental
Death Benefit..
iii. Optional Covers 1, 2, 3 & 4 as mentioned above, if opted shall continue for all the subsequent renewals of the policy, provided the policy
is renewed with us without any break
iv. Optional Covers 5, 6, 7 & 8 as mentioned above, if opted at the first inception of this Policy with us, shall continue for all the subsequent
renewals of the policy, provided the policy is renewed with us without any break. It cannot be opted at the time of renewal of the policy.

Add Ons for TATA AIG Health Supercharge:

Waiver of Higher Zone Co-Payment - UIN: TATHLIA25019V012425

Modification of Mandatory Sub-limits - UIN: TATHLIA25020V012425

The above-mentioned Add-On Cover(s) can be selected at policy level only and is applicable for Geo Plan only.
3. DETAILS OF THE PERSON(S) TO BE INSURED
Height Weight
Sr No. Name of the Insured Person Gender Relationship with Proposer* Date of Birth
(cms) (kgs)
1 Sambit Basu MALE Self 27/11/1991 170 75
2 Manomita Singha FEMALE Spouse 01/02/1994 165 50

*Allowed Relations (Self, Spouse, child(ren), dependent Parents/ parents-in-law)

If the entry Age of the Insured Person is 61 years or above at the time of first coverage under this Policy, then such Insured Person shall
bear 20% of each admissible claim (over and above any other Co-payment, if applicable).
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
MANOMITA SINGHA 01/02/1994 Spouse -

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 2 of 6
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.
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 Persons
Insured Person by ticking the relevant box. 1 2
Decline Disease Name N N
Have you or any of the persons proposed for insurance, ever suffered from or 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, N N
flu or for minor injuries that have completely healed?
Are you or any persons proposed on regular medication (including any N N
Ayurvedic 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
without any follow-up tests/medications? – Elevated Blood Sugar/ Type 2
Diabetes Mellitus/ Elevated Blood Pressure/ Hypertension/High Cholesterol/
Asthma>> (Mandatorily “Yes”, if ‘Advanced Cover’ is opted as Optional Cover for
eligible members.)
Is any of the insured pregnant currently? If yes, please mention expected date of N N
delivery (EDD). Any history of pregnancy related complications?
Has any application for life, Health or critical illness insurance ever been N N
declined, 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
Have you or any members ever been diagnosed with Thyroid Disorder? If yes, N N
please provide details for follow-up tests/medications
Do you have any signs, symptoms, illness or injury including knee joint ligament 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 N N
examination in the past year which showed any significant findings? If yes,
please provide details for findings or results

B. Detailed information in case any of the questions in section 6 (A) is ticked ‘Yes’.
(Please send us medical documents along with this proposal form.)

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 3 of 6
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

Alcohol (in ml) - -

Per Day
Per Week
Per Month
Occasionally
Smoking (No of Cigarettes or Bidis/day) 4 Daily - 8 Years -
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

7. PAYMENT DETAILS
Name of the Premium Payer:
(if different from proposer) SAMBIT BASU
Relationship with the proposer:
(if different from proposer) -
Premium Amount (in ₹) : 11357
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. I / we shall keep the company informed if we subsequently
become a Politically Exposed Person.
**“Politically Exposed Persons” shall have the meaning assigned to it under sub clause (xii) of 3(b) of Chapter I of Master Direction –
Know Your Customer (KYC) Direction, 2016 issued by Reserve Bank of India (RBI), 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: SAMBIT BASU Date: 24/01/2025

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 4 of 6
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:
Bank Branch: -
Account Number :
Bank IFSC code:
Account Type SB Account Current Account Others (please specify) -

9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

I here by 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 am 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 the Proposer : Sambit Basu Date : 24/01/2025

GoGreen: I would like to protect my environment and would like to help save paper by authorizing Tata AIG General Insurance
Company Limited to send all my policy and service related communication to the email id as mentioned in this application form. For
detailed terms, conditions, exclusions and policy wordings please refer our website (www.tataaig.com)

10. DECLARATION/VERNACULAR DECLARATION

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 Proposer: Sambit Basu
Name & Signature of agent/intermediary with Code: DIRECT (D2C INBOUND CALL CENTER) 0007652002

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: Sambit Basu

Name & Signature of agent/intermediary: DIRECT (D2C INBOUND CALL CENTER) 0007652002

11. AGENT DECLARATION

I, DIRECT (D2C INBOUND CALL CENTER) 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.

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 5 of 6
License No.(Intermediary/Corporate Agent/Broker/Relationship Officer) : NA
Name of the specified Person and code : DIRECT (D2C INBOUND CALL CENTER) & 0007652002
Place: MUMBAI
Date : 24/01/2025 Signature of Agent : DIRECT (D2C INBOUND CALL CENTER)

12. Section 41 of the Insurance Act 1938 (PROHIBITION OF REBATES)

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.

13. FOR OFFICE USE ONLY

Tata AIG Office Code:0200 Intermediary Code and Name: 0007652002-DIRECT (D2C INBOUND
Branch Receipt Date: ______________________________________ CALL CENTER)
Channel Type: _______________________________________________________
Business type: Urban Rural Social
Customer ID: ________________________________________________________

14. ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)

Proposal Number: PPR/BT/2846/7090039654 Date: 24/01/2025
Name of the Proposer: Sambit Basu
We acknowledge with thanks the receipt of your application for Tata AIG Health SuperCharge and amount by Payment of amount of Rs.
11357. 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-fulfillments of Pre Policy Checkup 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 premium paid 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.

Authorized Signatory

docit-digital-sign
Digitally Signed by: Shammi Kapoor
Date: 24/01/2025
Location: Mumbai

TATA AIG General Insurance Company Limited

Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, mumbai-400013
24*7 Toll free Number: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No. 108 | CIN No:U85110MH2000PLC128425 | TATA AIG Health SuperCharge UIN: TATHLIP24113V012324
Page 6 of 6