Kotak Group Assure (UIN:107N051V04) Kotak Group Shield (UIN:107N050V05)

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Kotak Complete Cover Group Plan (UIN:107N018V06) Kotak Credit Term Group (UIN:107N006V04)
Membership Form cum Declaration of Good Health
IMPORTANT NOTE : Any additional text written or qualification given in the form would make it invalid.

Name of the Policyholder : C I Capital Private Limited Policy Number : CD000158

PLAN DETAILS :
Sum Assured (`) :- Premium (`) : - Cover Term :5 years Plan Option : Life Cover
Premium Payment Term: ✔ Single Pay Limited Pay Regular Premium Premium Payment Mode: ✔ Single Yearly Half Yearly Quarterly Monthly

Cover Type: ✔ Single Life Joint Life Interest Rate : - Benefit Multiplier : 100% 110% 120% Moratorium Period :
LIFE ASSURED'S DETAILS
Loan Account No. : Customer ID:
Member Name: Mr. / Ms. Date of Birth : D D / M M / Y Y Y Y
Address: ____________________________________________________________________________________________________________________________ Gender: M F
Name of Joint Life Insured (if any): Mr. / Ms.
Date of Birth : D D / M M / Y Y Y Y Gender: M F Relationship with Member: ___________________________________________
NOMINEE DETAILS (needs to be a major i.e. above 18 years of age and should be one of the following: Husband, Wife, Son, Daughter, Father, Mother, Brother, Sister, Grandfather or Grandmother)
Name :
Relationship to Life to be Insured :
*Incase of Nominee being a Proprietor/Partnership Firm/Limited Company the above condition would not apply.
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.DECLARATION OF GOOD HEALTH
I hereby declare that :
1. I am in good health and perform all my routine activities independently
2. I have never had any physical defect, deformity or disability (means inability to function normally, physically or mentally) affecting my day to day activities.
3. I have never undergone nor have I been advised to undergo any major surgical procedure.
4. I have never suffered and am not currently suffering from:
a) High Blood Pressure, Heart Attack or any other Heart Disease; b) Stroke, Paralysis in any form, or any other Cerebrovascular Disease;
c) Diabetes or any other Endocrinal Disease, Kidney Disease; d) Any Chronic Liver Disease or any Cancer or Cancerous growth;
e) Any Lung Disease (eg. Chronic Obstructive Pulmonary Diseases, TB, Parenchymal lung Disease, Pulmonary Embolism etc).
f) Blood Disorders, Gastro-Intestinal Diseases, or any other disorder of the bones, spine or muscle;
g) Any Mental or Psychiatric condition, Epilepsy, any Genetic Disease or any disease related to central nervous system (disease related to brain);
h) HIV / AIDS or AIDS related complications.
5. In the last 2 years, I have not –
a) Have a reduction in weight (of more than 10 kgs) b) been continuously hospitalised for more than 7 days (other than fractures of leg or arm).
c) undergone any investigations (including basic radiological and blood tests) other than normal Health Check-ups and Insurance Medicals, or
d) had adverse result for any blood tests, X-Rays, ECG, Stress Test, Biopsies, CT Scan, MRI, Ultrasonography or 2D / 3D Echo etc.
6. I do not engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature.
7. For Females Lives Only: a) I am currently not pregnant. I am not suffering from or nor have suffered from any complication of pregnancy.
b) I am not suffering from or nor have suffered from any diseases of breast/ uterus/ cervix?
Following questions are applicable ONLY when "Critical Illness Cover / Disability Cover" are opted
8. I have not had any proposal and / or policy for life, health, accident or critical illness, including renewals / revivals therefor, declined or deferred by any insurance company in India or
Overseas. I do not engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature.
9. I have never been diagnosed with any form of internal or external congenital anomaly or defect. i.e. any condition(s) which is present since birth, and which is abnormal with reference to
form, structure or position.
DECLARATION BY THE MEMBER
I further declare that the above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Kotak Mahindra Life
Insurance Company Ltd.[KLI]. I further hereby agree and give my consent to, the Policyholder for use of the contents of this declaration by KLI for examining and processing any claim
arising, in respect of the insurance cover that may be provided to me under the referred group policy.
I hereby confirm that my intent to participate in the above plan for the Policyholder's customers is purely on a voluntary basis, I confirm and I confirm and agree that the insurance cover, if
provided, will be governed by the provisions of the Insurance Act, 1938 and the Policy Contract under which the cover will be offered to me. I agree and understand that if I contract any of the
above diseases between submitting this document and the date of commencement of the cover, I shall not be covered under the policy. I have also not withheld any material information or
suppressed any fact. I undertake to notify KLI ('The Company') of any change in my state of health or occupation or any decisions subsequent to the signing of this declaration form and
before the acceptance of the risk by the Company. I understand and agree that if any untrue statement be contained herein, I, my heirs, executors, administrators or assignees shall not be
entitled to receive any benefits which may be provided to me on the faith of this declaration, including, inter alia the aforesaid insurance cover. I understand and acknowledge that insurance
cover shall be as per terms and conditions detailed in the Policy Contract issued by KLI in favour of the policyholder and that KLI's decision in respect of all aspects of the referred group life
insurance plan shall be final & binding. I hereby agree to and authorize the Policyholder / my Doctor / Hospital / Local, State, Central authority / Dealer / Distributor /my Employer to divulge or
convey any information or particulars relevant to this Form / my admission into the referred Group Insurance Policy to KLI at any point during the continuance of my cover hereunder including
any claim under the said Policy. I also permit KLI to approach me directly for any clarification related to this proposal and resulting policy I further agree that in case of fraud / mis-
representation by me, the Policy will be treated in accordance with the Section 45 of the Insurance Act,1938 and amendments there to from time to time.
Place : ______________________________________Date :________________________Signature/Right Thumb impressions of life to be insured___________________
AUTHORISATION OF CLAIM PAYMENT (applicable only for Regulated Entities*)
I authorise KLI to apply the benefits under this policy, first towards the loan outstanding, by paying the same directly to the Policyholder and the balance, if any, may be paid to myself and/or
my nominee/legal heirs, as the case may be. I certify that this authorization is being effected in consideration of a loan obtained from the Policyholder. I further certify that the loan outstanding
amount as confirmed by the Policyholder shall be considered as final and binding. I declare that the receipt of the benefits by the Policyholder and/or my nominee/ legal heirs shall be a valid
and sufficient discharge of KLI's liabilities with respect to the life cover provided to me.
*Regulated Entities shall include: I. (a) Reserve Bank of India (“RBI”) regulated Scheduled Banks (including co-operative Banks), (b)NBFCs having Certificate of Registration from RBI or (c)National
Housing Bank (“NHB”) regulated Housing Finance Companies (d) National Minority Development Finance Corporation (NMDFC) and its State Channelizing Agencies (e) Small Finance Banks
regulated by RBI; II. (f) Mutually Aided Cooperative Societies formed and registered under the applicable State Act concerning such Societies (g) Microfinance companies registered under section 8
of the Companies Act, 2013 (h) any other category as approved by IRDAI
Place : ______________________________________Date :_______________________Signature/Right Thumb impressions of life to be insured___________________
DECLARATION WHERE SCRIBE IS INVOLVED (COMPULSORY FOR ALL DECLARATIONS SIGNED IN ANY VERNACULAR LANGUAGE)
I ________________________________________________ (full name of scribe) have explained to the borrower the contents of this form in his own language and he/ she has fully
understood the same. Also, I have explained that if any untrue statement is contained herein, the borrower, and/or the heirs, executors, administrators, assignees of the borrower shall not be
entitled to receive any benefits, including, inter alia, benefits under any insurance policy procured on the faith of this Form.
Place : ______________________________________________ Date : _______________________ Signature of the Scribe : _____________________________________________________

Place : ______________________________________________Date : ________________________ Witness / Policyholder Authorized Signatory : _________________________________

Section 41 of the Insurance Act, 1938 states: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take 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.
Section 45 of the Insurance Act, 1938 States: The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above contract. Please refer to Section 45 either on our website
or contact our intermediary or visit the nearest branch for the full text.
Free Look Period : The member is offered 15 days free look period from the date of receipt of the Certificate of Insurance wherein the Member may choose to return the Certificate
of Insurance within 30 days of receipt if s/he is not agreeable with any of the terms and conditions of the plan and receive the applicable refund amount.
Kotak Mahindra Life Insurance Company Ltd. CIN : U66030MH2000PLC128503, Regn. No.: 107, Regd. Office: 2nd Floor, Plot# C-12, G-Block, BKC, Bandra (E),Mumbai- 400 051.
Website: http://insurance.kotak.com Email:clientservicedesk@kotak.com. Toll Free No.–1800 209 8800
Ref No.KLI /20-21/Jul-08
Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.