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Policy Schedule
Tata AIG MediCare
Intermediary Name: AXIS BANK LTD
Intermediary Code: 0015455000
Intermediary Contact No.: 1800 209 2001 (mobile or
landline)
Issuing Office : JAIPUR
Client Id : 0008525425
Proposal no. : IDV000498022
Policy holder’s Name: DHARAM CHAND SONI
Policy holder’s Address: 39-A D K NAGAR JHOTWARA
,RAJASTHAN,
JAIPUR - 302012
JAIPUR
RAJASTHAN
INDIA
Place of supply -RAJASTHAN
State code -08
Insured GST No:
Place of Supply: RAJASTHAN
Supply Code: 08
Policy Number: 0238463683
Product name: Tata AIG MediCare
Plan type: Floater Plan
Business Type: Renewal Business
Policy Tenure: 1 Year
Policy Period: From : 26/05/202300:00 hrs TO: 25/05/2024 on 11:59 PM
Premium Payment Zone Zone C

Insured Persons Details:

Insured
with Tata
Insured AIG Relationship
Person's General Age Restore Cumulative
Insurance Member Date of (in to Benefit Sum Accidental
Name Co. since Id birth years) Policyholder % Insured ( ) Bonus ( ) Death
DHARAM
CHAND 26/05/2014 ZZZZ713631501036 11/07/1977 45 Self 100% 0.00
SONI 300,000.00 240,000.00
HEMANT

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SONI 26/05/2014 ZZZZ713631504015 24/07/1998 24 Son 100% 0.00

KANTA
26/05/2014 ZZZZ713631502037 13/12/1976 46 Spouse 100% 0.00
SONI

Net Premium is inclusive of discount for no coverage for Global Cover for Planned Hospitalization

* For Family Floater policy, Sum Insured and cumulative bonus floats among the insured persons of the family as mentioned
above. Earned Cumulative Bonus shall not be applicable for newly added members in this policy.

# Sum Insured mentioned is excluding cumulative bonus. Earned cumulative bonus is separately mentioned.

Net Premium ( ) : 17,190.00

Loadings ( ) : 0.00
Discounts ( ) : 6,685.00
Tax, Duties and cess as
applicable ( ) :
UGST/SGST @9 % ( ) : 1,547.10
CGST @9 % ( ) : 1,547.10
Gross Premium ( ) : 20,284.00
Gross Premium (In Words) : Rupees Twenty Thousand Two Hundred Eighty Four And Paise Zero Only

Benefit Name Coverage Limit

Vaccination cover Upto 5000 per policy
In-Patient Treatment - Dental Upto Sum Insured
Organ Donor Upto Sum Insured
Post-Hospitalization expenses Upto 90 days
In-Patient Treatment Upto Sum Insured
Ambulance Cover Upto 3000 per Hospitalization
Compassionate travel Upto 20,000 per policy year
Restore benefits Upto Sum Insured
Second Opinion Covered
Daily Cash for Accompanying an Insured Child 0.25% of base Sum Insured; maximum 2000 per day
Health Checkup Upto 1% previous year Sum Insured; max. 10,000 per policy
Consumables Benefit Upto Sum Insured
Day Care Procedures Upto Sum Insured
Pre-Hospitalization expenses Upto 60 days
Bariatric Surgery Cover Upto Sum Insured
Hearing Aid 50% of actuals; maximum 10,000 per policy
Domiciliary Treatment Upto Sum Insured
Daily Cash for choosing Shared Accommodation 0.25% of base Sum Insured; maximum 2000 per day
AYUSH Benefit Upto Sum Insured
Global Cover Upto Sum Insured
Wellness Service 8 teleconsultations (GP) and Ambulance Booking Facility.

Nominee Details for Policyholder :

Nominee Name Relationship to Policyholder

KANTA SONI Wife
DHARAM CHAND SONI Wife
KANTA SONI Wife
DHARAM CHAND SONI Wife
KANTA SONI Wife
DHARAM CHAND SONI Wife

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Continuity benefit is already considered for this policy no.

Policy Comments if applicable -

l Claim Servicing
Details:
l Name of Claim
: Tata AIG Health Claim
Administrator
l Website : www.tataaig.com
l Email : customersupport@tataaig.com
l Toll Free : 18002667780
: 1800229966 (For Senior Citizens)
l Submit claim : TAGIC Health Claims Claims processing HUB ,
TATA AIG General Insurance Company Limited
5th and 6th Floor, Imperial Towers H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet Hyderabad - 500016,

Stamp Duty of 30/ - is paid as provided under Article 47-C of Indian Stamp Act, 1899 and included in Consolidated Stamp
Duty Paid to the Government of Maharashtra Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp
Office, Fort, Mumbai - 400001., vide this Order No. LOA/CSD/655/2023/1021 Validity Period Dt.24/03/2023 To
Dt.30/01/2050/ Date:
Policy Servicing Address :
Policy Servicing Office
Tata AIG General Insurance Company Limited
PLOT NO C 93 – C 94 , 1ST FLOOR, OFFICE NO -101-103,, FORTUNE HEIGHTS , SUBASH
MARG ,,JAIPUR,RAJASTHAN,JAIPUR-302001
Tel No:91-91-7400010048

Authorized Signatoryalf of Tata AIG General Insurance Company Limited Date:

Authorized Signatory

In the event of non-realization of premium, the Company shall not be liable under the policy and the policy shall stand
cancelled ab initio (from inception).
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam
Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai- 400 013.
IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : AABCT3518Q UIN No : TATHLIP23118V032223
Website: www.tataaig.com 24X7 Tollfree Helpline 1800-266-7780 E-mail: customersupport@tataaig.com

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Certificate of Premium payment for the purpose of declaration under Section 80 D of Income Tax (Amendment) Act,
1961*

Date : 26/05/2023
Policy Number : 0238463683
Customer Name : DHARAM CHAND SONI
Address Line 1 : 39-A D K NAGAR JHOTWARA, ,RAJASTHAN,,
Address Line 2 : JAIPUR-302012
Address Line 3 : RAJASTHAN
GSTIN no :

Dear Sir/Madam,

Sub: Tax Benefit Letter for Medicare policy no. 0238463683

This is to certify that premium amount of Rs 20284( Rupees Twenty Thousand Two Hundred Eighty
Four And Paise Zero Only) for health insurance Policy No 0238463683 issued to DHARAM CHAND
SONI for the period 26/05/2023 to 25/05/2024 has been paid.

Receipt Illustration

Receipt ID. Name of Payer Mode of payment Amount paid

DEBIT
102001047678026 DHARAM CHAND SONI 20,284.00
AUTHORIZATION
Total Amount Paid 20,284.00

Premium illustration (Member wise)

Total member
Relationship with premium paid
Member ID Name of Member
Policyholder (Including Taxes &
Loading)
ZZZZ713631501036 DHARAM CHAND SONI Self 6,206.00
ZZZZ713631504015 HEMANT SONI Son 4,990.00
ZZZZ713631502037 KANTA SONI Spouse 9,088.00
Total Premium Paid (Inclusive of Loading &
20,284.00
Taxes collected)

Please feel free to get in touch with us for any further help or queries at our 24x7 Helpline
18002667780 (Toll-free) or email us at customersupport@tataaig.com

We assure you of our best services at all times.

Regards,
For Tata AIG General Insurance Company Limited

Authorized Signatory
Date of
26/05/2023
Issue :
Place of
JAIPUR
Issue:

Note

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1. Tax deductions can be claimed subject to the provisions prescribed in the relevant sections of the Income-tax Act, 1961 as
amended from time to time.
2. Premium paid in advance will be applied to the policy on premium due date.
3. This premium paid certificate is conditional upon credit in company's account post clearance of the instrument/facility
including electronic mode.
4. For any confirmation / impact analysis, customer is advised to refer the matter to his/her Tax consultant.
5. This certificate must be surrendered to the company in case of cancellation of this policy. In the event of incorrect
representation of this declaration the liability shall be upon the policyholder/payer.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam
Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai- 400 013.
IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : AABCT3518Q UIN No : TATHLIP23118V032223
Website: www.tataaig.com 24X7 Tollfree Helpline 1800-266-7780 E-mail: customersupport@tataaig.com

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RECEIPT

Receipt No. : 102001047678026 Receipt Date : 05/05/2023

Policy No : 0238463683 03 00

Received with thanks from MR DHARAM CHAND SONI a sum of 20,284.00 ( Rupees Twenty Thousand
Two Hundred Eighty Four And Paise Zero Only) vide Card no. XXXXXXXXXXXX9999

Utilized from the receipt

Sr. Policy
Total Premium ( ) for Balance ( )
No. Number
policy ( )
1 0238463683 03 00 20,284.00 20,284.00 0.00

Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be
considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.

GSTIN : 08AABCT3518Q1ZW - RAJASTHAN Service Accounting Code : 997133

Revenue (consolidated) Stamp Duty duly paid vide challan No.LOA-NO.CSD/507/4491 date 18/10/2022 for
applicable cases.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam
Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai- 400 013.
IRDA Registration No.108, CIN No : U85110MH2000PLC128425,PAN : AABCT3518Q
Website: www.tataaig.com 24X7 Tollfree Helpline 1800-266-7780 E-mail: customersupport@tataaig.com

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Tata AIG MediCare

Name : DHARAM CHAND SONI

Age : 45
Gender : M
Policy No. : 0238463683 03 00
From : 26/05/2023 To 25/05/2024
Member ID : ZZZZ713631501036
Please refer to our website or mobile application to know the
list of cashless network hospitals and excluded hospitals
TAGIC Health ClaimsTATA AIG General Insurance
Company Limited
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad -
500016,Telangana,
Toll Free : 18002667780, Website : www.tataaig.com
Tata AIG MediCare UIN: TATHLIP23118V032223

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Tata AIG MediCare

Name : HEMANT SONI

Age : 24
Gender : M
Policy No. : 0238463683 03 00
From : 26/05/2023 To 25/05/2024
Member ID : ZZZZ713631504015
Please refer to our website or mobile application to know the
list of cashless network hospitals and excluded hospitals
TAGIC Health ClaimsTATA AIG General Insurance
Company Limited
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad -
500016,Telangana,
Toll Free : 18002667780, Website : www.tataaig.com
Tata AIG MediCare UIN: TATHLIP23118V032223

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Tata AIG MediCare

Name : KANTA SONI

Age : 46
Gender : F
Policy No. : 0238463683 03 00
From : 26/05/2023 To 25/05/2024
Member ID : ZZZZ713631502037
Please refer to our website or mobile application to know the
list of cashless network hospitals and excluded hospitals
TAGIC Health ClaimsTATA AIG General Insurance
Company Limited
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad -
500016,Telangana,
Toll Free : 18002667780, Website : www.tataaig.com
Tata AIG MediCare UIN: TATHLIP23118V032223

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Annexure to customer information sheet (CIS) Benefit illustration in respect of policies offered on individual and family floater
basis.

Coverage opted on Coverage opted on individual basis

individual covering Coverage opted on family floater basis
Age of the basis covering each multiple members of the family under with
member member of a single overall sum insured(only one sum
Insured the family seperately policy(sum insured available for each insured
(at a single member of available for entire family
point of time) the family
Premium
or
consolidated
Premium Sum Floater Premium Sum
Sum Discount premium
Premium Premium after Insured( discount after Insured(
Insured if any for all
Discount ) if any Discount )
members
of the
family
45 7305 28% 5259.6
24 5873 28% 4228.56 300000
46 10697 28% 7701.84
Total premium for all
members Total premium for all members of the
The premium when the policy is opted on
of the family is when family is
floater
each member is when they are covered under a single
basis is 17190
covered policy
seperately
Sum insured available sum insured available for each family Sum insured of 300000 is available for
for each member is the
individual is entire family
Note: Premium rates specified in the above illustration shall be standard premium rates without considering any loading.
Also the premium
rates shall be exclusive of taxes applicable.

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Online Proposal Form - Tata AIG MediCare

URN No.: AH/2021-22/HL-03

Proposal no. - IDV000498022 Intermediary Code: -0015455000

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 cancelation of
policy.

Please fill-up this form in CAPITAL LETTERS

1. PROPOSER’S DETAILS
First Name Middle Name Surname

Date of Birth(dd/mm/yyyy) - Gender - MALE

Mobile - 9462595041
Unique Govt ID No. -
Annual Income in Rs(Lakhs) - 0.00 Upto 3 / 3 to 6 / 6 to 10 / 10-15/ 15-20/ 20-25/ >25
E-Mail ID - No-reply@tataaig.com
39-A D K NAGAR JHOTWARA
Address^
,RAJASTHAN,
Landmark - Area -
City/Town -JAIPUR Pin Code -302012
District -JAIPUR State -RAJASTHAN
Nationality Indian Foreign Nationals
Is Residence Status of either the Policyholder or any of the Insured Person(s) is Non Resident Indians (NRI)/ Overseas
Citizen of India (OCI)/ Foreign Nationals? Yes* No

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
Tata Group Employee
Tata Group Employee ID:

2. POLICY DETAILS
Proposed Policy Commencement Date:
To

Plan Type Floater Basis

Policy Tenure 1 Year
Room(Category)All Room Categories Covered
Accidental Death Benefit Yes

l Riders shall be opted by all the eligible members. There cannot be selection between the eligible members for
choosing riders.
l Dependent Children will not be covered under Personal Accident Benefit.

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3. DETAILS OF THE PERSON(S) TO BE INSURED

Name of the Insured Relationship with Date of
Sl No Gender Height Weight Sum Insured(Rs)#
Person Proposer* Birth
1 DHARAM CHAND SONI Male Self 11/07/1977 175 70 300000
2 HEMANT SONI Male Son 24/07/1998 167 59
3 KANTA SONI Female Spouse 13/12/1976 162 65
* Allowed relations (Self,Spouse, children and dependent parents/parents in law)
# Options available (3, 4, 5, 7.5, 10, 15, 20 Lakhs); Same Sum Insured for all members in floater
option
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
KANTA SONI 01/01/1900 Wife
DHARAM CHAND SONI 01/01/1900 Wife
KANTA SONI 01/01/1900 Wife
DHARAM CHAND SONI 01/01/1900 Wife
KANTA SONI 01/01/1900 Wife
DHARAM CHAND SONI 01/01/1900 Wife
*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:

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):IDV000498022
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 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

Insured Person
Please answer each of the following questions individually for each
Insured Person by ticking the relevant box.
1 2 3 4 5 6 7

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 undergone a surgery for the following medical
conditions?

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Decline Disease Name NO NO NO NO NO NO NO

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 NO NO NO NO NO NO NO
undergone a surgery for MediCal Conditions specified on Proposal
form?

Any other illness/disease/injury/disability in the past other than for

NO NO NO NO NO NO NO
childbirth, flu or for minor injuries that have completely healed?

Are you or any persons proposed on regular medication (including

NO NO NO NO NO NO NO
any Ayurvedic treatment) or awaiting any procedure/treatment?

Have you ever been diagnosed with any of these medical conditions
with or without any follow-up tests/medications? – Elevated Blood
NO NO NO NO NO NO NO
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 delivery (EDD). Any history of pregnancy related NO NO NO NO NO NO NO
complications?

Has any application for life, Health or critical illness insurance ever
been declined, postponed, loaded or been made subject to any NO NO NO NO NO NO NO
special conditions by any insurance company?

Has any health or life insurance policy ever been terminated in the
NO NO NO NO NO NO NO
past?

Have you ever been diagnosed with any Thyroid Disorder with or
NO NO NO NO NO NO NO
without any follow-up tests/medications?

Do you have any signs, symptoms, illness or injury including knee

joint ligament tear or back pain/ Swelling or Pain in any part of body /
Breathlessness on mild effort / dizziness more than once in last 6 NO NO NO NO NO NO NO
months for which medical consultation / treatment / investigation has
been required

Have you undergone any annual health check-up or routine medical NO NO NO NO NO NO NO

examination in the past year? (If yes, please provide details of any

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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 application form.)

C. Lifestyle Information

Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? No
If yes please indicate the name and quantity per day.

Insured Person

Alcohol (in ml)

Smoking (No of Cigarettes or Bidis)

Pan Masala/Tobacco (in gms)

Others habit forming

substances/addictive (Quantity
consumed)

7. PAYMENT DETAILS

Name of the Premium Payer: DHARAM CHAND SONI

Relationship with the proposer: Self
Premium Amount (in ): 20284
Instrument type: DEBIT AUTHORIZATION
Please make a Crossed Cheque/DD/Pay Order in favour of ‘Tata AIG General Insurance Company Limited’ only.
Sources of funds: OTHERS

Anti Money Laundering (AML) declarations

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

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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 (Pls tick)
l Limited company
l Government organization
l Non-Governmental Organization (NGO)
l Society
l Trust
l Partnership
l International Organization
l Cooperatives
l Section 25 Company
Signature of Proposer & Date :

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 (RTGS) / 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 HSBC BANK
Branch Bank
Account no.
Bank IFSC code
Account Type SB Account Current Account Others(please specify)

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

n I 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
am authorized to propose on behalf of these other persons.
n 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.
n 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.
n 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

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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.
n 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.
n Signature of the Proposer:
n 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 the proposer:

Name & Signature of agent/intermediary with code: AXIS BANK LTD 0015455000

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: AXIS BANK LTD

11. AGENT DECLARATION

I,AXIS BANK LTD 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

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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
CA0069
Agent/Broker/Relationship Officer)
Name of the specified Person and code: AXIS
BANK LTD 0015455000

Place: JAIPUR Date: Signature of Agent: AXIS BANK LTD

12. SECTION 41 OF 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 : Intermediary Code and Name:AXIS BANK LTD
Branch Receipt Date: Channel Type:AGENT CORPORATE
Business Type: Urban/ Rural/ Social Customer ID -

Tata AIG General Insurance Company Limited.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully, before concluding a sale. Tata AIG General Insurance Company Limited. Registered Office: Peninsula
Business Park, Tower A, 15th Floor, G. K. Marg, Off Senapati Bapat Road, 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

14. ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)

Proposal Number: IDV000498022 Date:

Name of the proposer:

We acknowledge with thanks the receipt of your proposal for Tata AIG MediCare and amount by DEBIT AUTHORIZATION of
amount of 20284. 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

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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 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.

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