MAX LIFE INSURANCE COMPANY LIMITED

Regd. Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District, Nawanshahr, ,
Punjab -144533
Corporate Office: 11th & 12th Floor, DLF Square, Jacaranda, Marg, DLF City, Gurugram, 122002, Haryana

Group Credit Life Secure Application-cum-Health Declaration Form

Master Policyholder Name (MPH): Toyota Financial Services
Group Policy No. Car Loan - Reducing Cover : 35006381 Car Loan - Level Cover 35006380
PRODUCT NAME: Max Life Group Credit Life Secure
LOAN APPLICATION NO. LOAN A/C NO.

(USE BLOCK LETTERS) First Middle Last

Name of the Life to be insured

Date of Birth (DDMMYYYY) Gender Male Female

Marital Status Single Married Widowed Divorced Height (in CMs) Weight in KGs

Relationship with Group Policyholder: Borrower Key Person for Loan Repayment (Co-Borrower) Co-borrower
Guarantor (only one of the four options to be selected)

Premium financed by MPH Yes No Period of Insurance (In Years) ROI % .

Occupation: Salaried Self-employed Self-employed from home Professional Agriculture Retired Student Housewife Others

Education: Illiterate Primary school l High /Secondary school Graduate Post Graduate Diploma

PAN Number (of Life to be Insured) : Annual Income (INR)

Reference/Cheque No Amount (Provide details only in case Premium financed by MPH is ‘No’))

Sum Assured

Communication Address
City State Pin
Mobile No. State Landline No. Pin Code
Email ID
Nationality Indian NRI Others If others, please specify place of residence
Sr. Please answer the following questions in Yes or No
No. YES NO
1. Do you have any life or health insurance policy issued/pending/lapsed with Max Life Insurance Company Ltd or with any other company? If yes, please provide the
proposal/policy number/application no. _________________________________________
2 Have you consulted any doctor for treatment or are under treatment for any ailment other than common cough or cold or undergone any surgical operation at a hospital or
clinic or undergone any investigations with other than normal or negative results (including X rays, ECG, blood tests, biopsies etc.) or have you been absent from work due to
any illness or injury for a continuous period of more than 7 days during the last 5 years or is any surgery planned or are you currently aware that you may need to seek medical
advice in the near future?
3 Have you ever been diagnosed with or received treatment for any disability or medical condition such as but not limited to high cholesterol, any complaints of blood pressure
disorders, chest pain, any heart disease , raised blood sugars or diabetes, stroke, transient ischemic attack or any other cerebrovascular disease , paralysis, cancer or any
tumor, lump of any kind, asthma or any other respiratory disease, mental or any neurological disease or disorder, any liver disease (including Hepatitis B or C), any blood
disorders (including anemia), any digestive and bowel disorder, thyroid or any other endocrine disorder, kidney and urinary tract disease,; prostate or gynecological disorder,
any disorder of the bones, spine or muscle, muscle ,deformity, amputation or arthritis , problems of stones in any organ in the body, HIV infection, AIDS or AIDS related
complex or do you have any congenital/birth defects or any other medical condition not listed above ?
4 Have any of your applications, including applications for life, critical illness, health, accident or any other riders including simultaneous/renewals/revivals ever been declined,
deferred, withdrawn or accepted at extra premium or reduced cover or offered any special terms by Max Life or any other insurance company in India or overseas?

5 Have you ever been involved or planning to be involved in an occupation, sport or hobby of a dangerous or hazardous nature such as mining, diving, mountaineering,
parachuting, private aviation, racing, etc.?
6 Do you have any parent and /or brother or sister who has suffered/suffering from, or died under the age of 60 due to any of the following conditions: Heart disease, diabetes,
stroke, hypertension, raised cholesterol, cancer, multiple sclerosis, Alzheimer disease, Parkinson disease or any hereditary disease?
7 Were you ever hospitalized for Covid infection or its complication or do you have any ongoing complications related to Covid Infection?

8
Do you drink Alcohol or smoke or consume tobacco in any form like chewing tobacco? If yes please state number of cigarettes per day _______/ day

Have you ever been convicted or are you under investigation for any criminal charges? Yes /No
9
If yes give details

Please provide complete details for all the above questions answered “YES”

SFQ Form Version 2.1 Sep’2023

Name of Beneficiary
Date of Birth Relationship with the Assured
Gender: Male Female
Please provide Appointee details in case Beneficiary is minor i.e., not attained the age of 18 years
Name of Appointee:
Date of Birth Relationship with the Beneficiary
Gender: Male Female

Please Note: The Master Policyholder (MPH) has tied-up with Max Life Insurance Company Ltd. for “Max Life Group Credit Life Secure” policy, wherein MPH is the Group Policyholder. The policy offers
protection to Loan customers of MPH against loan liability in case of an eventuality. The selected option `borrower’ or `co-borrower’ or ‘guarantor’ will only be covered as life insured under this policy.
The insurance cover shall be equal to the Sum Assured (in no case should exceed the loan amount) opted by the life to be insured. In case 'Reducing Cover' is opted, Sum Assured will reduce periodically
as per the Sum Assured schedule. In case 'Level Cover' is opted, Sum Assured will remain constant throughout the term of coverage. Coverage is voluntary for all eligible members of the scheme and by
signing this Application cum Declaration of Health Form you agree to enroll yourself within the Group Policy. Also, please note that completion of this Form does not mean automatic commencement of
insurance coverage. This is only an Application cum Health Declaration Form. You may be required to undergo medical examinations if the need arises and the coverage is not effective while this
application is under process. Insurance cover shall commence only after satisfactory completion of medical & financial underwriting conducted by Max Life Insurance Co Ltd and subsequent written
confirmation by Max Life Insurance Co Ltd conveying the Commencement of insurance coverage & issuing a Certificate of Insurance.
Declaration: I hereby declare that I fully understand the meaning and scope of health declaration form and the questions contained above and am submitting the completed health declaration of my
own volition. I further agree and declare that the statements and declarations herein shall be the basis of the insurance cover being extended on my life and that I have made complete, true and accurate
disclosure of all the facts and circumstances as may be relevant. I have not withheld or suppressed any information or facts that may be relevant and material to enable the company to make an
informed decision about the acceptability of the risk on my life. Should any statements /s be incomplete, false, wrong or inaccurate or misleading or should there be any omission/s or suppression on my
part in disclosing the relevant information, the company shall have the right to cancel the insurance cover on my life, if issued and forfeit any payments received. I fully understand that the issuance of
the policy shall be subject to my undergoing medical tests as per the company norms. I undertake to notify the company, forthwith in writing of any change in any of the statements made herein above
subsequent to the signing of this Health Declaration Form and prior to acceptance of risk by the company. I also Understand that if I foreclose/fully repay the loan for any reason, then I have an option to
either continue coverage as per original terms or opt to surrender the benefits under the policy. I/We authorize Max Life to appropriately adjust the amount of sum insured and/or coverage tenure
depending upon the final premium amount remitted to Max Life by the Master Policyholder. I understand that the final coverage terms will be as per COI issued by Max Life.
Authorization by the individual member of the Group Life Insurance Scheme/Policy
[Applicable only in respect of lender-borrower groups i.e (i) Reserve Bank of India (RBI) regulated Scheduled Banks (including Co-operative Banks), (ii) Non-Banking Financial Companies (NBFCs ) having
Certificate of Registration from RBI, (iii) National Housing Board (NHB) Regulated Housing Finance Companies, (iv) National Minority Development Finance Corporation (NMDFC) and its State Channelizing
Agencies, (v) Small Finance Banks regulated by RBI, (vi) Mutually Aided Cooperative Societies formed and registered under the applicable State Act concerning such Societies, (vii) Microfinance
Companies registered under Section 8 of the Companies Act, 2013, or (viii) any other entity as may approved by the IRDAI]:
I hereby authorize Max Life Insurance Company Limited (“Max Life”) to pay the outstanding loan balance as provided in the Credit Account Statement (to be provided by the Master Policyholder) to MPH
("Master Policyholder"), in respect of the loan availed of by me from the Master Policyholder (the application number of which is mentioned herein), by deducting the same from the claim proceeds
payable to my nominee/beneficiary under this group policy on the happening of the insured event.
"I further give my consent to and authorize Max Life to pay other proceeds, if any, in favor of Master Policy Holder"
I hereby give my consent to MPH to share “documents related to Loan” and other income documents with the insurer for the purpose of underwriting my insurance application.
I have given my consent to Max Life Insurance to sent the communications through SMS, Email & Whats App related to my Policy.

Signature of Life to be insured: _________________________ Date: Place:

D ec la r at io n by R e l at io n s hip Of f ic e r/ Sal e s M a n a ge r / C han n e l Pa rt n e r R e p re se n t at i v e:

 I hereby declare that I have fully explained the contents of Health Declaration Form to the life to be insured and I have truthfully recorded the answers given by the life to be insured
Signature ______________________ Name: ____________________________ Code: __________________________

Vernacular Declaration (to be signed by declarant only if the applicant has signed in any other language except English)
I hereby declare that I have fully explained the contents of Health Declaration Form to the life to be insured and I have truthfully recorded the answers given by the life to be insured.
Declarant's signature: _________________________________________________ Date:
Name & Address

MPH Section (To be filled by MPH officials)

ASC Code: ASC Location Source Code:
MPH Emp ID: Max Life Insurance Co Ltd Source ID:
Declaration by MPH
Name of Applicant (life to be insured): _______________________ Relationship: As mentioned On Pg 1 Other____________

Loan amount sanctioned: INR _________ ___ Loan Tenure:________ Type of Loan:_________________ _Type of Firm (if Firm is Primary Applicant): _____________

Applicant’s Occupation: _____As mentioned On Pg 1 ____Other_______________ Applicant’s assessed annual income:____ As mentioned On Pg 1 Other____________
 We have verified the signature, age and the income details as provided by the provided by the life assured (who is the primary borrower/ co-borrower) against
records available with us, which are, Age Proof- School certificate/Passport/Birth Certificate/Driving License (please select), Income Proof- Form 16/Income Tax
returns /Latest Pay Slip/Appointment letter (please select) and ID Proof- PAN/Passport/Driving License (please select).
 All necessary information as required by Max Life Insurance Co. Ltd. is collected and presented herewith. Only standard age proof accepted.
 Key Person Co-borrower Section: As per Lender’s assessment, Life to be Insured is Key Person towards loan repayment Yes No
 Rationale (tick one or more): Key to run the Firm/Business Major Holding in Firm Income has been assessed for loan Other ______________________

 Co-borrower Section – To be filled only if Primary borrower has not applied & only co-borrower has applied for insurance (Ignore, if above Key Person Dec. is filled)
 Reason why primary borrower is not applying for cover: _______________________Reason for covering co-borrower _________________________________
 Relation of Co-borrower with Primary Borrower: _____________________ Income of Co-borrower assessed Yes No

Signature of MPH Officials (Please affix branch stamp): ________________________________ Date:

Date and Stamp – Form Handed over to Max SM:

SFQ Form Version 2.1 Sep’2023