Proposal Form -

"Care Supreme"

In reference to your online proposal (1120091494008) for "Care Supreme" Comprehensive Health Insurance policy, please find below the
details as provided by you:

Proposer Details

Name Address Date of Birth Mobile

116 16 laxminagar colony, laxminagar colony Pochampalle

MR. Vanam Yadagiri Naigonda, Nalgonda, TELANGANA, 508284 01-JAN-1973 XXXXXX5322

Landline E-mail Nominee Name Nominee DOB PAN Details

0va*************@gmail.c
Vanam shyamala 01/01/1978 Not Available
om

Details of the Persons be Insured

Date of Height Weight

Relation Name Pre-existing Diseases
Birth (cm) (kg)

SELF MR. Vanam Yadagiri 01-JAN-1973 170 70 NONE

SPOUSE MS. Vanam Shyamala 01-JAN-1978 163 50 DIABETES (03/2022)

Additional Details
A. Does any person(s) to be insured has any pre-existing diseases?
MR. Vanam Yadagiri MS. Vanam
Shyamala
NO YES
B. Have any of the person(s) to be insured ever filed a claim with their current/ previous insurer ?
MR. Vanam Yadagiri MS. Vanam Shyamala

NO NO
C. Has any of your proposal(s) for Health insurance been declined, cancelled or charged a higher
MR. Vanam Yadagiri MS. Vanam Shyamala

NO NO
D. Is any of the person(s) proposed for insurance covered under any other health insurance policy with
MR. Vanam Yadagiri MS. Vanam Shyamala

NO NO
You agreed to following terms & conditions of the purchase of policy
a. I have read and understood the brochure/prospectus/sales literature/Terms and Conditions of the Policy and confirm to abide by the same.

b. Receipt of proposal form by the Company shall not be construed as acceptance of proposal. Commencement of risk under the Policy shall
be subject to realization of full premium and individual underwriting by the Company. The Company at its sole discretion reserves the right to
accept or reject or load any proposal. Policy would start from the date as specified in the Policy Certificate.

c. I understand that the Policy Period Start Date as specified in the Policy Certificate shall be from the 00:00 hours of the next day of the
Proposal receipt at branch, proposed policy period start date as opted by me or cheque date, whichever is later.

d. I understand that the Policy shall become void at the Company's option, in the event of any untrue or incorrect statement,
misrepresentation, non-description or non-disclosure of any material fact, in the proposal form/personal statement, declaration and connected
documents or any material information having been withheld by me or anyone acting on my behalf.

e. I hereby declare that the lives proposed to be insured would submit to medical examinations before the nominated doctors of the Company
or undergo diagnostic or other medical tests, as suggested by the Company for its underwriting.

f. I consent to and authorize the Company and/or any of its authorized representative agents to seek medical information from any
hospital/medical practitioner or any other related entity that I have attended or may attend in future concerning any illness or injury.
g. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.

h.I authorize the Company to exchange, share or part with the information relating to myself/person(s) to be insured with any external entity
other than regulatory and statutory bodies, as may be required and I will not hold the Company or its agents liable for use/sharing of this
information.

i. I/We agree and undertake to convey to the Company any change/alterations carried out in the risk proposed for insurance after submission
of this proposal form.

j. I/We consent to receive information from the Company the through physical, electronic or
telecommunication means from time to time. the undersigned hereby declare on my behalf and on behalf of
each of the persons proposed to be insured that the above statements and particulars are true, accurate
and complete and correct in all respects and that there is all information which is relevant to this
proposal that has been disclosed and not withheld from the Company. I declare that the money used to
make the premium payment has not been derived from any illegal activity or unaccounted funds. I further
declare and agree that this declaration and the answers given above shall be held to be promissory and
shall be the basis of the contract between me/us and the Company.

You also agreed to receive service SMS and E-mail alerts.

Proposer's (Signature)

Servicing NA,XXXXXXXXXXX,XXXXXXXXXX(00) - 0

Care Health Insurance Company Limited

Servicing NA,XXXXXXXXXXX,XXXXXXXXXX(00) - 0
Correspondence address : Care Health Insurance Limited, Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector - 43,
Gurugram - 122009 (Haryana).
Contact No : 1800-102-4488 Fax:1800-200-6677
Website : www.careinsurance.com RCM Applicability - NA
SAC and Description of Service: 997133- Accident and Health Insurance Services.
Email : [email protected] Consolidated Stamp Duty paid vide F.No.10 (17685)/COS(HQ)/CD
dated 10th Jan 2015
GST Registration No :
XXXXXXXXXXX
IRDA Registration Number - 148 UIN : IRDA/NL-HLT/RHI/PP/ V.I/255/13-14