22nd Floor, A Wing, Marathon Futurex Loan a/c no.

N.M. Joshi Marg, Lower Parel (E). Mumbai - 400013.

CIN: U66010MH2007PLC167164
IRDAI Regestration no. 135 0522675100072089
Toll Free: 1800 209 0502
E-mail:[email protected], www.ageasfederal.com
Application No: 125164298

MEMBER ENROLLMENT FORM

Ageas Federal Life Insurance Group Home Secure Plan (UIN: 135N092V01)

Master Policy No. MP000019 MasterPolicy Holder Name IDBI Bank

Servicing branch code 8012 Application receipt date 16/05/2025
Servicing branch name RAC Pimpri Acknowledgement (ACK) number
Bank/Distributor name IDBI Cheque deposit date/Fund transfer date
URN number Ageas Federal employee code 115266
Loan Details
Bank customer ID Branch credit manager code
ST1 code DSAASKFI Branch sales manager code 106041
ST2 code Branch operation manager code
New loan Yes Existing loan No
Top-Up Loan

General instructions & warnings: 1. While answering questions in this form and providing any other information in respect of the insurance, the
borrower must make a full and frank disclosure of all material facts. If a full and frank disclosure is not made of all material facts, or if any material fact is
misrepresented, the policy issued is liable to be cancelled with immediate effect in accordance with section 45 of insurance act, 1938 as amended from
time to time. Further details on this section are provided on page 2. 2. Please read the sales literature to understand the products. 3. All corrections made
in this form have to be duly countersigned. 4. Wherever space provided is insufficient, please use additional sheets to provide details. 5. All questions
have to be answered. 6.Please fill this form in block capitals and tick option chosen wherever applicable. 7. The requirement of disclosure of material
information in this form or policy apply both to the insured and the insurer.8. Member Enrollment Form and Addendum to Member Enrollment Form is to
be read together.
PART-I: DETAILS OF MEMBER TO BE INSURED/JOINT LIFE
MEMBER TO BE INSURED JOINT LIFE (If any)
1. Title Mr
2. Gender Male
3. Name Anil Lakshuman Maskar
4. Date of birth 01/12/1994
5. Marital Status Married
Indian
If NRI/PIO/please mention the country & city of residence and date If NRI/PIO/please mention the country & city of residence and date
6. Nationality
of last entry to India of last entry to India
(Please submit the copy of passport showing latest entry to India) (Please submit the copy of passport showing latest entry to India)
7. Educational qualification Diploma
Tapasya Niwas Sr No 70/621/9 Near HDFC Bank Ganesh Nagar
Shivaji Chouk New Sangavi
8. Mailing Address PIN : 411027 City: Pune State : Maharashtra PIN : City: State :
(Member Address)
Email: [email protected] Email :
Mobile: 9623368649 Tel (With STD code): Mobile : Tel (With STD code):
Salaried
9. Occupation Name of organization: Utility Solutions Name of organization:
Designation: Team Leader Designation:
10. Annual Income 6,30,000
Applicable if annual premium equals or Applicable if annual premium equals or
11. PAN DLOPM6422G
exceeds Rs. 50,000 exceeds Rs. 50,000
12.Nature of work Administrative
13. Relationship with primary
Self
member to be insured
14. UID ID No
15. Do you have Electronic
no If Yes, fill the Electronic If Yes, fill the Electronic
Insurance Account

PART-II : DETAILS OF EXISTING INSURANCE OF THE MEMBER TO BE INSURED/JOINT LIFE

MEMBER TO BE INSURED JOINT LIFE (If any)
1. Please provide the details of existing life/critical illness/credit life cover details OR 1. Please provide the details of existing life/critical illness/credit life cover details OR
pending/simultaneous insurance cover for fresh/lapsed notices OR any pending/simultaneous insurance cover for fresh/lapsed notices OR any
declined/postponed/rated up/null & void/not taken up on life assured/joint life in the declined/postponed/rated up/null & void/not taken up on life assured/joint life in the
below table. below table.
If yes, please provide the following details. If yes, please provide the following details.
Policy / Application Total Sum Assured Name of Insurance Policy / Application Total Sum Assured Name of Insurance
Acceptance Terms* Acceptance Terms*
number (in Rs.) Company number (in Rs.) Company
1.
2.
*Please indicate if risk is accepted at Ordinary Rates or with Extra Mortality Rates or Declined
PART-III : LOAN & PLAN DETAILS
A. Plan Details
1. Cover Options : single
2. Cover Benefit : Level Death Benefit Option

AFLI/NB/IDBI/MEF/GLSPII/V1.3/112024 Page 1 of 5
3. Initial Sum Assured (Rs*) : 3436663 *Initial Sum assured (including premium, if funded by the financial institution)
4. Cover Term : 300 months 5. Premium Payment Term : Single
B. Premium Details
2. Total payment (Rs) : 1,36,662 (Instalment premium payable including GST &
1. Premium mode : Single
cess with respect to member to be insured)
C. Loan details
1. Loan type : Home Loans 2. Loan A/C No. : 0522675100072089
3a. Moratorium period without interest accrued in moratorium: 0 months 3b. Moratorium period with interest accrued in moratorium : 0 months
4. EMI Account : 26,573 5. EMI Frequency : 6. Loan term (including moratorium, if any): 300 years
7. Loan amount : 33,00,000 (Please mention sanctioned loan amount.Premium funded by bank/lending institution to be excluded)
8. No of co-borrowers : (For proportionate cover only) Every co-borrowers need to fill a separate member enrollment form
9. Share of loan (For Co-borrowers cover only): % The total proportionate share of loan across all co-borrowers should be 100%
10. Loan interest rate : % 11. Date of first disbursement: 09/06/2025 12. LIP A/C No.:
D. Payment method: Direct Debit
Cheque/DD number & date: Bank Name: Branch: Amount:
Incase of direct debit/standing instructions/ECS
Account Number: Bank Name: Branch: Amount:
*Please fill up the addendum to MEF for health declaration.
PART-IV : NOMINEE DETAILS
1. Particulars of the nominee (As per section 39 of Insurance Act 1938) (The person to whom the money secured by the policy shall be paid)
Date of %
Name Gender Relationship Address with contact number
Birth Share
1.Jyoti Bajirao Tapasya Niwas Sr No 70/621/9, Near HDFC Bank Ganesh Nagar, Shivaji Chouk New Sangavi, 411027,
Female Spouse 25/08/1994 100
Kasote Pune, Maharashtra contact: 9096745134
2.
If nominee is minor, please mention the name of appointee (appointee has to be an adult), relationship of appointee with nominee

(appointee has to be different from the member to be insured) DOB of Appointee:

PART-V: DECLARATION AND AUTHORISATION

I/We understand that this form has been filled for becoming an insured member of Ageas (ii) if a proposal for assurance or an application for revival of a policy on my life made to
Federal Life Insurance Group Home Secure Plan and I/We (name of the entity) to be the any other insurer is withdrawn,deferred, declined or accepted at an increased premium or
master policyholder. I/We the undersigned authorize Ageas Federal Life Insurance Co Ltd. subject to a lien or on terms other than as proposed, I/We shall forthwith intimate the
(Ageas Federal Life) to settle claims under the member cover in the following manner: - At same to the Company in writing. I/We consent,authorise and direct any doctor, hospital,or
the time of claim settlement Ageas Federal Life will call for a credit account statement from employer to disclose to the Company any information relating to my present state of
the master policyholder. health and my past health history. I/We agree and declare that in event of me being
If the master policyholder is either of the following medically examined, the answers given by me to the medical examiner acting on behalf
1. Reserve Bank of India (RBI) Regulated Scheduled Commercial Banks (including Co- of Company shall be deemed to be part of the statements and answers given in relation
operative Banks) to this application and they shall form basis of this application.I/We agree that the risk
2. NBFCs having Certificate of Registration from RBI cover proposed under the master policy may not commence till the Company accepts this
3. National Housing Bank(NHB) Regulated Housing Finance Companies application and communicates to me the commencement of risk by way of certificate of
4. National Minority Development Finance Corporation (NMDFC) and its State Channelizing insurance except to the extent as specifically mentioned in the master policy document.
Agencies I/We declare that the premiums paid have not been generated from the proceeds of any
5. Small Finance Banks regulated by RBI criminal activities/ offences and I/We shall abide by and conform to the Prevention of
6. Mutually Aided Cooperative Societies formed and registered under the applicable State Money Laundering Act, 2002 and amendments made therein or any other applicable
Act concerning such Societies laws. I/We understand that in case of fraud or misstatement by me , action will be
7. Microfinance companies registered under section 8 of the Companies Act, 2013 initiated as per provisions of section 45 of the insurance act 1938 as amended from time
8. Any other category as approved by the Authority and if there is any outstanding loan to time.
balance, the claim proceeds will be paid to the master policyholder to the extent of I/We authorise Ageas Federal to use my mobile number/email ID as mentioned above for
outstanding loan balance. Balance claim amount (if any) will be payable to the beneficiary. sending alerts relating to this enrolment and resulting COI. I authorise the master
In case of Master Policy Holder is other than those stated above the death benefit is policyholder to pay the premium payable on my behalf/collected from me. I/We authorise
directly paid to the beneficiary of the insured member. I/We hereby declare and warrant on disclose the insurer such particulars as they may require including the details given
my behalf that all the answers given in response to the questions herein above and the above and changes to the same such as loan details, personal details.
statements made in this form or otherwise in support of this application are true,correct I/We authorize the Master Policyholder to provide information to Ageas Federal Life
and complete in all respects, and there is no other information material to this application Insurance Company Ltd. in electronic mode regarding my personal details related to
that has not been disclosed. I/We further agree that if after the date of submission of the name, date of birth, gender, address, occupation, details regarding Know Your Customer
application but before the issue of Certificate of Insurance there is (i) any change in my (KYC), Prevention of Money Laundering Act related documents, and other material
occupation or any adverse circumstances connected with my financial position or my information as required for issuance of the cover.
health or I/We authorise Ageas Federal to also send me the Policy Document electronically.

....................................................................................................... .......................................................................................................

Signature/thumb impression of the member to be insured Signature/thumb impression of the joint life to be insured

Place: ................................... Date: .......................................... Place: ................................... Date: ..........................................

Declaration to be given if this form is signed in vernacular or if the members to be and ensured that the contents have been fully understood by him/her. I/We have
insured has used thumb impression instead of signature: accurately recorded the member to be insured's responses to the information sought in
I/We, have explained the contents of this form to the member to be insured in________ this form and I/We have read out the responses to the member to be insured and he/she
(language) and ensured that the contents have been fully has confirmed that they are correct.

.............................................................. ............................................................... ...............................................................

Signature of the Specified Person/Agent/Broker Signature/thumb impression of the member to Signature/thumb impression of the joint life to
making the declaration: be insured be insured

.....................................................................
Place: .............................................. Place: ..............................................
Name of the Specified Person/Agent/Broker

......................................................................
Date: ................................................. Date: .................................................
Address

AFLI/NB/IDBI/MEF/GLSPII/V1.3/112024 Page 2 of 5
 22nd Floor, A Wing, Marathon Futurex Loan a/c no.
N.M. Joshi Marg, Lower Parel (E). Mumbai - 400013.
CIN: U66010MH2007PLC167164
IRDAI Regestration no. 135 0522675100072089
Toll Free: 1800 209 0502
E-mail:[email protected], www.ageasfederal.com

Application No: 125164298

ADDENDUM TO MEMBER ENROLLMENT FORM
Ageas Federal Life Insurance Group Home Secure (UIN:135N092V01)

Proposal Number
Servicing branch code 8012 Application receipt date 16/05/2025
Servicing branch name RAC Pimpri Acknowledgement (ACK) number
Cheque deposit date/Fund transfer
Bank/Distributor name IDBI
date
URN number Ageas Federal employee code 115266
Loan Details
Bank customer ID Branch credit manager code
ST1 code DSAASKFI Branch sales manager code 106041
ST2 code Branch operation manager code
New loan Yes Existing loan No
General instructions & warnings: 1. While answering questions in this form and providing any other information in respect of the insurance, the borrower must make a full and frank
disclosure of all material facts. If a full and frank disclosure is not made of all material facts, or if any material fact is misrepresented, the policy issued is liable to be cancelled with immediate
effect in accordance with section 45 of insurance act, 1938 as amended from time to time. Further details on this section are provided on page 2. 2. Please read the sales literature to
understand the products. 3. All corrections made in this form have to be duly countersigned. 4. Wherever space provided is insufficient, please use additional sheets to provide details. 5. All
questions have to be answered. 6.Please fill this form in block capitals and tick option chosen wherever applicable. 7. The requirement of disclosure of material information in this form or policy
apply both to the insured and the insurer.8. Underwriting questions/details for the person to be insured shall be obtained separately as per the applicable Underwriting Policy of the Company
from time to time. 9.Member Enrollment Form and Addendum to Member Enrollment Form is to be read together.
PART I - HEALTH DECLARATION OF MEMBER TO BE INSURED & JOINT LIFE
(To be filled for cover up to 40 Lacs for age 18 to 50 years only)
MEMBER JOINT
Sr.No. PERSONAL HEALTH STATEMENT TO BE LIFE (If
INSURED any)
Are you suffering from or have you ever suffered from any accident, illness, disease or ailment which required hospitalisation,
1. No
nursing-care or surgery or which led to residual disability of any sort?
Are you currently under treatment or medication or have you, in the past one year, been advised to undergo surgery, medical
2. No
investigation or medical treatment for any medical condition (other than minor conditions like cold, flu, etc.)?
Are you suffering from or have you ever suffered from or have ever been diagnosed or received treatment for medical conditions
such as but not limited to high blood pressure, Diabetes, chest pain, heart attack or any other heart condition; stroke, transient
ischemic attack or any other cerebrovascular disease; diabetes or raised blood sugar or Sugar in Urine or any other endocrinal
3. No
disease; kidney disease; HIV / AIDS or AIDS related complex; any cancer or tumour or Lump; asthma or any other respiratory
disease; any mental ornervous disease; hepatitis or any other liver disease; blood disorders; digestive disorders; paraplegia or any
other disorder of the bones, spine or muscle, or any other Medical condition not mentioned above?
Has any application or proposal for life, health, accident or critical illness including renewal and reinstatement ever been declined,
4. No
deferred, withdrawn or accepted at special rates or terms or with exclusions by any Insurance company?
Have any of your parents or brother(s) or sister(s) died before age 60 or suffered from diabetes, high blood pressure, cancer, heart
5. No
disease, raised cholesterol, kidney failure or stroke or any hereditary diseases?
If you answered “YES” to any of the above questions, please give complete details (including dates, duration and treatment, names and addresses of physicians) on the back of this form and include your signature and the date
PART II - PERSONAL HEALTH STATEMENT OF MEMBER & JOINT LIFE TO BE INSURED
MEMBER JOINT
Sr.No. PERSONAL HEALTH STATEMENT TO BE LIFE (If
INSURED any)
Are there any health conditions not mentioned below OR have you received any treatment OR have any sign / symptom for which
you have consulted any Doctor / Specialist OR undergone surgery OR Advised to undergo or undergone investigations like blood
1. tests, Xray, ECG, Echo, Ultrasound, CT Scan, MRI, Endoscopy, Colonoscopy, Biopsy, Angiography etc OR taken sick leave from work No
for more than 5 continuous days OR been hospitalised for more than 3 days for any medical condition including COVID-19 infection in
the last 5years.
MEMBER TO a. Height :5 feet 5 inches Joint Life a. Height :
2. BE INSURED (if any)
b. Weight :48 b. Weight :
Have any of your natural parents, brothers or sisters died or suffered from diabetes, hypertension, heart disease, stroke or cancer
below the age of 60 years?
3. No
If 'Yes' please provide relation with such persons, age in years and present state of health (if living), age at death in years and cause
of death (if deceased) in additional sheets.
Have you ever suffered from or currently under treatment for:
a) Diabetes mellitus, high blood sugar levels or sugar in urine? No
b) High blood pressure, cholesterol, lipids, chest pain, heart attack, heart murmur, shortness of breath or any other heart condition? No
c) Stroke, paralysis, transient ischemic attack, epilepsy, head injury, multiple sclerosis, tremors, dizzy or fainting spells, blurred or
No
double vision or any other neurological disorder?
d) Asthma, Tuberculosis, chronic cough, chronic bronchitis, COPD, emphysema, pneumonia, blood in sputum or any other respiratory
No
disorder?
e) Recurrent indigestion, ulcer, colitis, chronic diarrhoea, jaundice, hepatitis, cirrhosis, gall stone or any other disease of the stomach,
No
4. bowels, liver, gall bladder?
f) Kidney stone, blood in urine, recurrent urinary tract infection, enlarged prostate or any other disease of the kidney and bladder? No
g) Anaemia (Low Haemoglobin), Polycythaemia (High Haemoglobin), Leukaemia (blood cancer), Thalassemia, Bleeding, or any other
No
Blood Disorder?
h) Cancer, tumour, leukemia, enlarged lymph nodes or any abnormal growth or any hormonal disorders or disorders of the blood and
No
lymphatic system, eyes, ear, nose, throat
I) Arthritis, Gout or Joint Pain, Fracture, Spondylosis, Low Back Pain, muscular dystrophy, or any other Musculoskeletal Disorder? No
j) Loss of sleep, Anxiety, Depression, Panic disorder or any other mental disorder requiring treatment with anti-depressant? No
k) Thyroid (Hypothyroidism, Hyperthyroidism, Goitre) or any other Endocrine Disorder? No

AFLI/NB/IDBI/MEF/GLSPII/V1.3/112024 Page 3 of 5
 l) A positive test for HIV / AIDS, hepatitis (other than hepatitis A and E) or any sexually transmitted diseases? No
4.
m) Any other disease not state above? _________________________________________________________________________________________________
Is your occupation associated with any specific hazard or do you take part in activities or have hobbies that could be dangerous in any
5. No
way for example paragliding, bungee jumping, etc?
a) Do you smoke or chew
If 'Yes', please fill b, c, and d below: No
tobacco?
b) Type of tobacco MEMBER TO Cigarette: No Bidi: No Cigar: No PanMasala: No Gutka: No Chewing: No
BE INSURED
c) Amount consumed (per day) (sticks) (pouches)

d) Consuming since (in years) 0 Years

6.
a) Do you smoke or chew
If 'Yes', please fill b, c, and d below: No
tobacco?
b) Type of tobacco Joint Life Cigarette: Bidi: Cigar: PanMasala: Gutka: Chewing:
(if any)
c) Amount consumed (per day) (sticks) (pouches)

d) Consuming since (in years) Years

a) Do you consume alcohol? If 'Yes', please fill b, c, and d below: No
b) Type of alcohol Beer: No Wine: No Hard liquor: No

Less than once a week: No Once a week: No More than once a week: No Daily:
c) Frequency of consumption MEMBER TO
BE INSURED No

d) Amount consumed ml per week (Note: one small peg is 30 ml and one large peg is 60 ml)

e) Consuming since (in years) 0 Years

7.
a) Do you consume alcohol? If 'Yes', please fill b, c, and d below: No
b) Type of alcohol Beer: Wine: Hard liquor:

Less than once a week: Once a week: More than once a week: Daily:
c) Frequency of consumption JOINT LIFE
(if any)

d) Amount consumed ml per week (Note: one small peg is 30 ml and one large peg is 60 ml)

e) Consuming since (in years) Years

8. Have you ever used habit-forming (narcotics/psychotics) drugs or received any alcohol or drug abstinence treatment? No
9. Have you had or do you have any form of physical disability, deformity or defect? No
The following questions needs to be answered only if the Member to be insured OR Joint Life (if any) is a female:
a) Have you ever suffered /are suffering from or have ever undergone any investigation or treatment or received medical advice or
consulted a physician for any gynecological complications such as miscarriage, medical termination of pregnancy, disorders of cervix,
uterus, ovary(ies), breast(s), breast lump /cyst, fibrocystic disease etc.
10.
b) Are you pregnant at present? (MEMBER TO BE INSURED)
No
If yes, duration in weeks :
b) Are you pregnant at present? (JOINT LIFE (If any))
No
If yes, duration in weeks :
If your answer is 'Yes' to any of the above questions kindly give details (MEMBER TO BE INSURED):
11.
If your answer is 'Yes' to any of the above questions kindly give details (JOINT LIFE (If any)):
FOR MEMBER TO BE INSURED / JOINT LIFE

'I/We hereby declare and warrant on my behalf that all the answers given in response to the questions hereinabove and the statements made in this form or
otherwise in support of this application are true, correct, and complete in all respects, and there is no other information material to this application that has not
been disclosed. I/We understand that in case of fraud or misstatement by me , action will be initiated as per provisions of section 45 of the insurance act 1938 as
amended from time to time.’

Signature of the Specified Person/Agent/Broker making the declaration: Signature / Thumb Impression of the member to be insured

Name of the Specified Person/Agent/Broker: Place: ....................................

Address: Date: ....................................

Signature / thumb impression of the joint life to be insured

Place: ............................ Date: ............................

AFLI/NB/IDBI/MEF/GLSPII/V1.3/112024 Page 4 of 5
Instructions:-
1. Parties to the assignment should satisfy themselves before registration of assignment. 2.This form must be filled by the owner of the policy.
Aconditional assignment may be made, part assignment of a policy is not allowed. 3. An assignment in favor of survivor/s shall be valid. 4. The
assignment of a policy shall automatically cancel any nomination made in the policy, except where the policy is assigned to the insurer, in which case
the nominees' right shall be affected to the extent of the insurer's interest in the policy. 5. The assignment shall not be effectual against the company
unless it is duly completed and delivered to Ageas Federal Life Insurance Co. Ltd. 6.The assignment will be as per the section 38 of insurance act.

PART - VII : NOTICE OF ASSIGMENT

Notice is hereby given that I / we, Anil Maskar (Assignor 1) and (Assignor 2) the holder of the Insurance cover issued by

Ageas Federal Life Insurance, assign the rights and benefits of the said life insurance cover to the IDBI BANK (Assignee) Bank/Financial Institution, whose
registered office is at IDBI BANK RAC PIMPRI BRANCH OFFICE

Signed by me on : 10/06/2025 Place : Pune Reason of assignment : Loan Protection

Signature of Assignor 1 Signature of Assignor 2 Signature of Assignee with stamp

PART - VIII : DETAILS OF THE PERSON SIGNING AS WITNESS

1. Name of the Witness SWAPNIL RAMESHRAO SHIYALE
2. Address A-Wing, 1st Floor, Kamla Cross Roads, C T S No-209/B,S, Opp. PCMC Main Office, Pune
3. Pin Code 411018
4. Occupation Salaried

Signature of the Witness

SECTION 45 OF THE INSURANCE ACT, 1938 as amended from time to from the date of issuance of the policy or the date of
time: 1) No policy of life insurance shall be called in question on any commencement of risk or the date of revival of policy or the date
ground whatsoever after the expiry of three years from the date of the of the rider to the policy, whichever is later, on the ground that
policy, i.e., from the date of issuance of the policy or the date of any statement of or suppression of a fact material to the
commencement of risk or the date of revival of the policy or the date of expectancy of the life of the insured was incorrectly made in the
rider to the policy, whichever is later. 2) A policy of life insurance may proposal or other document on the basis of which the policy was
be called in question at any time within three years from the date of the issued or revived or rider issued: Provided that the insurer shall
issuance of policy or the date of commencement of risk or the date of have to communicate in writing to the insured or the legal
revival of the policy or the date of rider to the policy, whichever is later, representatives or nominees or assignees of the insured the
on the ground of fraud. Provided that the insurer shall have to grounds and materials on which such decision to repudiate the
communicate in writing to the insured or the legal representatives or policy of life insurance is based: Provided further that in case of
nominees or assignees of the insured the grounds and materials on repudiation of the policy on the ground of misstatement or
which such decision is based. 3) Notwithstanding anything contained in suppression of a material fact, and not on grounds of fraud, the
the sub-section (2), no insurer shall repudiate a life insurance policy on premiums collected on the policy till the date of repudiation shall
the ground of fraud of the insured can prove that the mis-statement of be paid to the insured or the legal representative or nominee or
or suppression of a material fact was true to the best of his knowledge assignees of the insured within a period of ninety days from the
and belief or that there was no deliberate intention to suppress the fact date of such repudiation. Provided further that nothing in this
or that such mis-statement of or suppression of material fact are within section shall prevent the insurer from calling for proof of age at
the knowledge of the insurer: Provided that in case of fraud, the onus of any time if s/he is entitled to do so, and no policy shall be
disproving lies upon the beneficiaries, in case the policyholder is not deemed to be called in question merely because the terms of the
alive. 4) A policy of life insurance may be called in question at any time policy are adjusted on subsequent proof that the age of the Life
within three years Insured was incorrectly stated in the proposal.

AFLI/NB/IDBI/MEF/GLSPII/V1.3/112024 Page 5 of 5