For Citibank customers. Apollo Munich HEALTH PLAN. Points to Remember

Transcription

1 Apollo Munich HEALTH PLAN For Citibank customers Points to Remember Apollo Munich Health Plan tailor made exclusively for the customers of Citibank to offer them coverages like never before. The Plan is designed to answer all your health insurance requirements and allows you to choose the plan option suited to your requirement. 1 Maximum Age: The maximum entry age is 65 years. There is no maximum cover ceasing age in this policy. 2 Minimum Age: The minimum entry age is 91 days. ren between 91 days and 5 years can be insured if either parent is getting insured under this policy. 3 The cover will be valid for 1 or 2 year(s) as opted. An additional 7.5% discount is offered on the premium if you choose a 2 year policy. 4 An individual and/or his family members namely spouse, dependent children, dependent parents or parents-in-law are eligible for buying this cover on an individual or floater basis. 5 A maximum of 6 members can be added in a single policy, whether on individual or floater basis. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law. 6 The insured and his family cannot select sum insured across variants in a single policy/application.

2 Features and Benefits: Apollo Munich Health Plan for Citibank customers - Individual Basic Sum Insured per Insured Person 2.00, 3.00, 4.00, , per Policy Year (Rs. in Lakh) 15.00, 20.00, 25.00, a) In-patient Treatment Covered Covered Covered 1b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days 1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days 1d) Day Care Procedures Covered Covered Covered 1e) Domiciliary Treatment Covered Covered Covered 1f) Organ Donor Covered Covered Covered 1g) Daily cash for choosing shared accommodation Rs.500 per day maximum upto Rs.3,000 Rs.800 per day maximum upto Rs.4,800 1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization 2) Restore Benefit 3) Multiplier Benefit Not Covered 4) e-opinion in respect to a critical illness 5) Health Checkup Benefit Not Covered 6) Outpatient Benefit 7) Hospital Daily Cash Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. Yes Yes Yes Rs.5,000 per individual post waiting period of 2 years Rs. 500 per day up to a maximum of 30 days on individual basis 1% of sum insured subject to a maximum of Rs.5,000 per insured person at the end of every policy year. Rs.10,000 per individual post waiting period of 2 years Rs. 1,000 per day up to a maximum of 30 days on individual basis Rs.800 per day maximum upto Rs.4,800 Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. For SI of 15 lacs : Upto 1% of the Sum insured subject to a maximum of Rs 7,500 per insured person at the end of every policy year. For SI of 20 lacs & above : Upto 1% of the Sum insured subject to a maximum of Rs 10,000 per insured person at the end of every policy year. Rs.25,000 per individual post waiting period of 2 years Rs 2,000 per day upto a maximum of 90 days on individual basis Normal or Caesarean Delivery Rs. 8) Maternity benefit 50,000* (*Including Pre/Post Natal limit Not covered of Rs. 3,500 and New Born limit of Not covered Rs.4,500) [Waiting Period of 3 years] 9) New Born Baby cover Not covered Covered Not covered Apollo Munich Health Plan for Citibank customers Family Floater Basic Sum Insured per family per 2.00, 3.00, 4.00, , Policy Year (Rs. in Lakh) 15.00, 20.00, 25.00, a) In-patient Treatment Covered Covered Covered 1b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days 1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days 1d) Day Care Procedures Covered Covered Covered 1e) Domiciliary Treatment Covered Covered Covered 1f) Organ Donor Covered Covered Covered 1g) Daily cash for choosing shared accommodation Rs.500 per day maximum upto Rs.3,000 Rs.800 per day maximum upto Rs.4,800 1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization Rs.800 per day maximum upto Rs.4,800 Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above

3 Apollo Munich Health Plan for Citibank customers Family Floater 2) Restore Benefit Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. 3) Multiplier Benefit Not Covered 4) e-opinion in respect to a critical illness 5) Health Checkup Benefit Not Covered 6) Outpatient Benefit 7) Hospital Daily Cash Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. Yes Yes Yes Rs.5,000 per family post waiting period of 2 years Rs. 500 per day up to a maximum of 30 days on individual basis Upto 1% of sum insured per policy subject to a maximum of Rs.5,000 per insured person at the end of every policy year. Rs.10,000 per family post waiting period of 2 years Rs per day up to a maximum of 30 days on individual basis Normal or Caesarean Delivery Rs. 8) Maternity benefit 50,000* (*Including Pre/Post Natal limit Not covered of Rs. 3,500 and New Born limit of Not covered Rs.4,500) [Waiting Period of 3 years] 9) New Born Baby cover Not covered Covered Not covered Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy. For SI of 15 lacs : Upto 1% of the Sum insured per policy subject to a maximum of Rs 7,500 per insured person at the end of every policy year. For SI of 20 lacs & above : Upto 1% of the Sum insured per policy subject to a maximum of Rs 10,000 per insured person at the end of every policy year. Rs.25,000 per family post waiting period of 2 years Rs 2000 per day upto a maximum of 90 days on individual basis Other Benefits Lifelong renewal: Renew your cover lifelong and stay covered forever. No sublimit or copay: Enjoy your health plan without sub limits and copays. Cashless transactions: Apollo Munich Health Plan for Citibank customers enables you to get treated on a cashless basis across 4000 hospitals in over 800 cities. No geography based sub-limits: No matter where you buy your policy you can get treated in any city or hospital you like in the country with no additional copays or sub limits. No claim based loading: We will never load your renewal premium because you claimed or fell ill after taking our policy. Quick turnaround time: You don t have to worry about pre-authorization, 90% of pre-authorization is done within 2 hours. Quick claim payment: When it comes to claim settlement, we re one of the fastest in the industry to honour every genuine claim. Easy upgrade: This health plan also comes with an easy upgrade option. You can upgrade your cover to the next slab at the time of your policy renewal. Tax benefits: You can avail tax benefits for the premium amount under Section 80 D of the Income Tax Act. (Tax benefits are subject to changes in tax) Exclusions: Any treatment within 30 days of cover except any accidental injury Any pre existing diseases/conditions will be covered after a waiting period of 2 years in Platinum Plan option & 3 years in Silver and Gold Plan. 2 year exclusion for specific diseases like cataract, hernia,hysterectomy, joint replacement etc Expenses arising from HIV or AIDS and related diseases Abuse of intoxicant or hallucinogenic substance like drugs and alcohol. Hospitalization due to war or an act of war or due to nuclear, chemical or biological weapon and radiation of any kind. Non-allopathic treatment, congenital diseases, mental disorder, cosmetic surgery or weight control treatments. For complete exclusions please refer to the policy document Renewal Incentives: Multiplier Benefit: A Bonus of 50% of the basic sum insured for every claim free year will be offered accumulating up to 100%. In the event of a claim, the bonus shall be reduced by 50% of the basic sum insured at the time of renewal. However this reduction will not reduce the sum insured below the basic sum insured of the policy. This benefit is applicable to only Gold and Platinum plan. Portability: If you are insured under another Insurer`s health insurance policy, You can transfer to Apollo Munich with all your accrued benefits and due allowances for waiting periods etc to the extent of sum of previous sum insured and accrued cumulative bonus and it shall not apply to any other additional increased sum insured. Terms of Renewal: We offer life-long renewal regardless of your health status or previous claims made under your policy, unless the insured person or any one acting on behalf of an insured person has acted in an improper, dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the policy pose a moral hazard. Grace Period - Grace Period of 30 days for renewing the policy is provided under this policy. Any disease/condition contracted during the Grace Period will not be covered and will be treated as a Pre-existing condition.

4 Maximum Age There is no maximum cover ceasing age in this policy. Waiting Period - The waiting periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of the Apollo Munich Health Plan for Citibank customers policy. Renewal premium are subject to change with prior approval from IRDA. Any change in benefits or premium (other than due to change in age) will be done with the approval of the Insurance Regulatory and Development Authority and will be intimated at least 3 months in advance. In the likelihood of this policy being withdrawn in future, intimation will be sent to insured person about the same 3 months prior to expiry of the policy. Insured person will have the option to migrate to similar indemnity health insurance policy available with us at the time of renewal with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break as per portability guidelines issued by IRDA. Basic Sum Insured Enhancement Sum insured can be enhanced only at the time of renewal subject to no claim have been lodged/ paid under the policy. If the insured enhances the basic sum insured one grid up, no fresh medicals shall be required. In cases where the basic sum insured enhanced is more than one grid up, the case shall be subject to medicals. In case of enhancement in the basic sum insured waiting period will apply afresh in relation to the amount by which the basic sum insured has been enhanced. However the quantum of enhancement shall be at sole discretion of underwriting. Any insured person in the policy has the option to migrate to similar indemnity health insurance policy available with us at the time of renewal subject to underwriting with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break. dependent after attaining the age of 25 years will be offered coverage under separate individual policy with all continuity benefits. Discounts: Family discount of 5% if 2 family members are covered and 10% if 3 or more family members are covered under Apollo Munich Health Plan for Citibank customers on Individual Sum Insured basis. 7.5% discount on premium if insured person is paying premium of 2 years in advance as single premium. Free Look Period: You have a period of 30 days from the payment debit date. If You have any objections to any of the terms and conditions, You have the option of cancelling the policy stating the reasons for cancellation and You shall be refunded the premium paid by You after adjusting the amounts spent on any medical check-up and stamp duty charges. You can cancel your policy only if You have not made any claims under the policy. All Your rights under this policy shall immediately stand extinguished on the free look cancellation of the policy. Free look provision is not applicable and available at the time of renewal of the policy. Termination (other than Free Look Period): The policyholder may terminate this policy at any time by giving us written notice or call 24 x 7 CitiPhone or post internet banking login, and the policy shall terminate when such written notice or call is received. If no claim has been made under the policy, then we will refund part of the premium paid after retaining premiums as applicable short period rates in accordance with the policy document. We may terminate this policy on grounds of misrepresentation, fraud, nondisclosure of material facts or noncooperation by the policyholder or any insured person or anyone acting on the policyholder s behalf or on behalf of an insured person upon 30 days notice by sending an endorsement to the policyholder s address shown in the schedule without refund of premium. Tax Benefit: The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act, subject to applicable tax laws. Disclaimer This is only a summary of the product features. The actual benefits available are as described in the policy, and will be subject to the policy terms, conditions and exclusions. Insurance products are the obligations only of the Insurance Company. They are not bank deposits or obligations of or guaranteed by Citibank N.A. Citigroup Inc or any of its affiliates or subsidiaries or any governmental agency. All claims under the policy will be solely decided upon by the Insurance Company. Citibank, Citigroup or any of its affiliates and group entities hold no warranty and do not make any representation about the insurance, the quality of claims processing and shall not be responsible for claims, recovery of claims or for processing of or clearing of claims, in any manner whatsoever. Insurance is a subject matter of solicitation. This document does not constitute the distribution of any information or the making of any offer or solicitation by anyone in any jurisdiction in which such distribution or offer is not authorized or to any person to whom it is unlawful to distribute such a document or make such an offer or solicitation. Participation by the bank s customers in an insurance product is purely on voluntary basis. IRS Circular 230 Disclosure : Citigroup, Inc, it affiliates, and its employees are not in the business of providing tax or legal advice to any tax payer outside of Citigroup, Inc and its affiliates. This brochure and any attachments are not intended or written to be used, and cannot be used or relied upon, by any taxpayer for the purpose of avoiding tax penalties. Any such taxpayer should seek advise based on the taxpayer s particular circumstances from an independent tax advisor Tax benefit are subject to changes in the tax laws. Citibank is a licensed corporate agent of Birla Sunlife Insurance Company Limited, Royal Sundaram Alliance Insurance Company Limited and Apollo Munich Health Insurance Company Limited under the composite license number This policy is underwritten by Apollo Munich Health Insurance Co. Limited with its registered office at Apollo Hospitals Complex, Jubilee Hills, Hyderabad-33. For more details on risk factors, terms & conditions, Please read the policy terms and conditions carefully before concluding sales. All Insurance applications are subject to the Insurance Company`s underwriting and acceptance Section 41 of the 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 prospectus or tables of the insurers. 2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.

5 Reach Us Customers can contact / get detailed process information for Post freelook cancellation/ termination/surrender/ and refund, Claims and Escalations / service queries CitiCARE@apollomunichinsurance.com; Log on to : Write to Apollo Munich Health Insurance Co. Ltd. 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Call: Tariff Sheet: Apollo Munich Health Plan for Citibank customers Annual Individual Premium (Inclusive of service tax) Age Group (Years) 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A ,006 7,980 9,032 9,720 14,394 15,722 21,556 22,647 23,679 27, ,807 8,969 10,227 11,049 17,861 19,694 26,273 27,781 29,205 34, ,547 9,862 11,285 12,214 20,043 22,158 29,466 31,205 32,849 38, ,885 12,810 14,891 16,252 26,932 30,077 38,661 41,249 43,695 52, ,944 15,379 18,009 19,730 33,039 37,071 47,008 50,324 53,456 64, ,845 18,986 22,384 24,604 41,762 47,048 58,977 63,325 67,433 82, ,724 25,086 29,805 32,887 56,600 64,057 79,117 85,251 91,044 1,12, ,292 33,311 39,822 44,076 76,380 86,743 1,05,882 1,14,407 1,22,460 1,51, ,542 39,815 47,680 52,819 92,442 1,05,086 1,28,108 1,38,509 1,48,332 1,84, ,397 47,123 56,561 62,728 1,10,911 1,26,252 1,53,209 1,65,829 1,77,749 2,21,091 >80 43,788 53,823 64,678 71,769 1,29,291 1,47,293 1,78,313 1,93,123 2,07,111 2,57,977 Annual Family Floater Premiums (Inclusive of service tax) Age Group (Years) 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C ,511 11,836 13,458 14,519 23,430 25,721 36,547 38,433 40,215 46, ,137 12,603 14,361 15,511 25,373 27,911 39,432 41,520 43,491 50, ,589 15,677 18,124 19,721 32,498 36,106 48,935 51,902 54,705 64, ,761 18,370 21,396 23,374 38,845 43,373 57,590 61,315 64,833 77, ,689 22,009 25,809 28,292 47,627 53,420 69,636 74,400 78,902 95, ,568 28,111 33,231 36,575 62,466 70,427 89,776 96,328 1,02,515 1,25, ,137 36,335 43,247 47,764 82,246 93,116 1,16,541 1,25,484 1,33,929 1,64, ,387 42,839 51,106 56,507 98,307 1,11,456 1,38,767 1,49,584 1,59,801 1,96, ,241 50,147 59,987 66,416 1,16,777 1,32,624 1,63,869 1,76,906 1,89,218 2,33,991 >80 46,633 56,847 68,103 75,457 1,35,155 1,53,665 1,88,973 2,04,199 2,18,580 2,70,878 Age Group (Years) 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C ,470 14,056 16,148 17,514 27,657 30,541 42,457 44,829 47,069 55, ,957 14,662 16,851 18,282 29,296 32,378 44,944 47,480 49,873 58, ,549 17,898 20,812 22,716 36,727 40,926 54,844 58,298 61,559 73, ,861 20,752 24,285 26,592 43,379 48,547 63,895 68,146 72,161 86, ,824 24,431 28,747 31,566 52,237 58,682 76,040 81,340 86,348 1,04, ,703 30,533 36,169 39,851 67,076 75,690 96,181 1,03,266 1,09,959 1,34, ,272 38,757 46,185 51,040 86,856 98,376 1,22,946 1,32,423 1,41,375 1,73, ,523 45,261 54,044 59,781 1,02,917 1,16,718 1,45,170 1,56,524 1,67,247 2,06, ,376 52,569 62,925 69,691 1,21,388 1,37,886 1,70,272 1,83,844 1,96,663 2,43,276 >80 48,768 59,269 71,041 78,733 1,39,767 1,58,927 1,95,376 2,11,139 2,26,026 2,80,163 Age Group (Years) 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C ,778 15,389 17,740 19,277 30,203 33,415 46,186 48,829 51,325 60, ,096 15,904 18,333 19,920 31,672 35,054 48,454 51,237 53,866 63,425

6 ,857 19,229 22,405 24,479 39,274 43,800 58,574 62,297 65,815 78, ,338 22,173 25,988 28,480 46,094 51,617 67,845 72,388 76,678 92, ,343 25,875 30,477 33,484 54,996 61,802 80,045 85,643 90,930 1,10, ,223 31,977 37,899 41,769 69,835 78,810 1,00,186 1,07,569 1,14,543 1,39, ,791 40,202 47,917 52,958 89,615 1,01,497 1,26,952 1,36,725 1,45,957 1,79, ,041 46,705 55,774 61,700 1,05,675 1,19,839 1,49,176 1,60,827 1,71,831 2,11, ,894 54,013 64,656 71,609 1,24,146 1,41,006 1,74,277 1,88,147 2,01,247 2,48,883 >80 51,287 60,714 72,772 80,651 1,42,524 1,62,047 1,99,381 2,15,441 2,30,610 2,85,768 Age Group (Years) 2A 2A 2A 2A 2A 2A 2A 2A 2A 2A ,419 12,543 14,304 15,453 25,412 27,978 39,343 41,454 43,447 50, ,106 14,369 16,470 17,844 29,683 32,800 45,607 48,170 50,591 59, ,584 18,438 21,428 23,382 39,194 43,707 58,473 62,185 65,691 78, ,858 22,206 25,975 28,437 48,078 53,838 70,850 75,590 80,067 96, ,282 27,316 32,122 35,263 60,299 67,754 88,022 94,155 99,946 1,21, ,135 35,363 41,836 46,064 79,707 89,898 1,15,004 1,23,387 1,31,306 1,60, ,120 46,956 55,874 61,699 1,07,498 1,21,662 1,53,289 1,64,942 1,75,948 2,15, ,593 57,622 68,698 75,934 1,33,449 1,51,211 1,89,746 2,04,359 2,18,160 2,68, ,276 68,701 82,094 90,844 1,61,099 1,82,804 2,27,916 2,45,771 2,62,634 3,23,957 >80 69,585 79,262 94,819 1,04,984 1,89,157 2,14,827 2,66,858 2,87,975 3,07,920 3,80,447 Age Group (Years) 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C ,032 14,319 16,444 17,832 28,800 31,826 44,162 46,651 49,002 57, ,606 16,021 18,457 20,048 32,832 36,372 50,118 53,030 55,779 65, ,196 20,214 23,569 25,760 42,581 47,553 63,292 67,384 71,246 85, ,584 24,108 28,270 30,990 51,703 57,961 75,978 81,126 85,989 1,03, ,035 29,248 34,457 37,860 63,983 71,945 93,226 99,775 1,05,962 1,28, ,888 37,296 44,170 48,661 83,391 94,089 1,20,209 1,29,009 1,37,320 1,67, ,874 48,891 58,208 64,296 1,11,183 1,25,854 1,58,494 1,70,564 1,81,962 2,23, ,347 59,554 71,032 78,531 1,37,133 1,55,403 1,94,950 2,09,980 2,24,174 2,75, ,029 70,634 84,428 93,441 1,64,784 1,86,995 2,33,120 2,51,393 2,68,650 3,31,403 >80 71,337 81,195 97,154 1,07,581 1,92,842 2,19,019 2,72,063 2,93,596 3,13,934 3,87,892 Age Group (Years) 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C ,991 16,539 19,133 20,828 33,027 36,645 50,071 53,046 55,857 66, ,426 18,078 20,946 22,820 36,756 40,837 55,631 58,989 62,161 73, ,156 22,434 26,258 28,755 46,808 52,373 69,200 73,777 78,102 93, ,684 26,488 31,158 34,209 56,237 63,134 82,283 87,957 93,317 1,12, ,171 31,670 37,395 41,135 68,593 77,207 99,630 1,06,715 1,13,406 1,37, ,023 39,718 47,108 51,937 88,001 99,350 1,26,612 1,35,948 1,44,766 1,76, ,010 51,312 61,146 67,572 1,15,793 1,31,116 1,64,899 1,77,502 1,89,408 2,32, ,482 61,976 73,970 81,807 1,41,744 1,60,665 2,01,354 2,16,920 2,31,620 2,85, ,164 73,056 87,366 96,716 1,69,394 1,92,256 2,39,525 2,58,331 2,76,094 3,40,688 >80 73,473 83,617 1,00,092 1,10,856 1,97,452 2,24,279 2,78,466 3,00,536 3,21,380 3,97,177 Age Group (Years) 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C ,300 19,203 22,369 24,439 38,097 42,437 57,069 60,638 64,011 76, ,565 20,545 23,940 26,157 41,450 46,197 62,145 66,049 69,737 83, ,464 25,098 29,495 32,367 51,878 58,165 76,199 81,371 86,256 1,04, ,161 29,349 34,639 38,094 61,680 69,358 89,765 96,082 1,02,048 1,23,743

7 ,689 34,581 40,936 45,088 74,131 83,539 1,07,234 1,14,973 1,22,284 1,48, ,541 42,629 50,650 55,891 93,537 1,05,682 1,34,215 1,44,206 1,53,642 1,87, ,528 54,222 64,688 71,526 1,21,330 1,37,448 1,72,502 1,85,760 1,98,284 2,43, ,001 64,887 77,512 85,761 1,47,281 1,66,997 2,08,958 2,25,178 2,40,496 2,96, ,683 75,967 90,908 1,00,669 1,74,931 1,98,587 2,47,128 2,66,589 2,84,972 3,51,812 >80 75,991 86,527 1,03,633 1,14,809 2,02,988 2,30,611 2,86,069 3,08,794 3,30,256 4,08,302 Age Group (Years) Premium (in INR) 1,820 2,263 2,741 3,054 4,308 4,914 6,014 6,511 6,979 8,686 The premium mentioned is annual premium. All premium are inclusive of service tax and applicable cess A family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policy under individual sum insured plan 2 Year Premium 2 Year Individual Premium (Inclusive of service tax) Age Group (Years) 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A ,961 14,763 16,709 17,982 26,629 29,086 39,878 41,898 43,806 50, ,702 15,678 17,814 19,211 29,836 32,760 44,242 46,646 48,918 57, ,442 16,593 18,920 20,440 33,043 36,435 48,606 51,395 54,029 63, ,127 17,419 19,898 21,518 35,062 38,714 51,558 54,563 57,400 67, ,811 18,245 20,877 22,597 37,080 40,993 54,511 57,730 60,770 71, ,975 20,971 24,213 26,332 43,452 48,318 63,017 67,020 70,803 84, ,138 23,698 27,549 30,067 49,823 55,643 71,523 76,310 80,836 97, ,042 26,074 30,433 33,283 55,473 62,112 79,243 84,704 89,865 1,08, ,946 28,450 33,317 36,500 61,122 68,581 86,964 93,099 98,894 1,19, ,629 31,787 37,363 41,008 69,191 77,809 98,036 1,05,125 1,11,822 1,36, ,312 35,123 41,410 45,517 77,259 87,038 1,09,107 1,17,151 1,24,751 1,52, ,826 40,766 48,274 53,179 90,985 1,02,772 1,27,737 1,37,433 1,46,592 1,79, ,339 46,409 55,138 60,841 1,04,710 1,18,505 1,46,366 1,57,714 1,68,432 2,07, ,415 54,017 64,405 71,191 1,23,007 1,39,490 1,71,124 1,84,684 1,97,492 2,44, ,491 61,626 73,671 81,541 1,41,304 1,60,475 1,95,882 2,11,653 2,26,551 2,80, ,347 67,642 80,939 89,628 1,56,160 1,77,442 2,16,440 2,33,947 2,50,483 3,10, ,203 73,659 88,207 97,716 1,71,017 1,94,409 2,36,999 2,56,241 2,74,415 3,40, ,618 80,418 96,423 1,06,881 1,88,101 2,13,987 2,60,218 2,81,512 3,01,625 3,74, ,034 87,178 1,04,638 1,16,046 2,05,186 2,33,566 2,83,437 3,06,783 3,28,835 4,09, ,021 93,375 1,12,146 1,24,410 2,22,187 2,53,029 3,06,658 3,32,031 3,55,995 4,43, >yrs 81,008 99,573 1,19,655 1,32,773 2,39,188 2,72,492 3,29,879 3,57,278 3,83,156 4,77,258 2 Year Family Floater Premiums (Inclusive of service tax) Age Group (Years) 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C ,445 21,897 24,898 26,860 43,345 47,584 67,612 71,102 74,398 86, ,024 22,607 25,733 27,777 45,142 49,609 70,281 73,957 77,428 90, ,603 23,316 26,569 28,695 46,940 51,635 72,949 76,812 80,459 93, ,872 26,159 30,049 32,589 53,531 59,215 81,739 86,416 90,832 1,06, ,140 29,002 33,529 36,484 60,122 66,795 90,529 96,019 1,01,204 1,20, ,149 31,493 36,556 39,863 65,992 73,517 98,535 1,04,726 1,10,573 1,31, ,158 33,985 39,583 43,241 71,863 80,239 1,06,542 1,13,433 1,19,941 1,43, ,866 37,351 43,665 47,790 79,987 89,533 1,17,684 1,25,537 1,32,955 1,59, ,575 40,717 47,746 52,340 88,110 98,827 1,28,827 1,37,641 1,45,969 1,76,245

8 60 39,088 46,361 54,611 60,002 1,01,836 1,14,559 1,47,456 1,57,924 1,67,811 2,03, ,601 52,005 61,477 67,664 1,15,561 1,30,291 1,66,086 1,78,207 1,89,653 2,31, ,677 59,613 70,742 78,014 1,33,858 1,51,277 1,90,844 2,05,176 2,18,711 2,67, ,753 67,220 80,007 88,363 1,52,155 1,72,264 2,15,601 2,32,146 2,47,769 3,04, ,609 73,236 87,276 96,451 1,67,011 1,89,229 2,36,160 2,54,438 2,71,701 3,34, ,465 79,253 94,545 1,04,538 1,81,868 2,06,194 2,56,719 2,76,731 2,95,633 3,64, ,881 86,012 1,02,761 1,13,704 1,98,952 2,25,774 2,79,938 3,02,003 3,22,843 3,98, ,296 92,772 1,10,976 1,22,869 2,16,037 2,45,354 3,03,157 3,27,276 3,50,053 4,32, ,283 98,970 1,18,483 1,31,232 2,33,037 2,64,817 3,26,378 3,52,522 3,77,213 4,67, >yrs 86,270 1,05,167 1,25,990 1,39,596 2,50,036 2,84,280 3,49,599 3,77,768 4,04,374 5,01,124 Age Group (Years) 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C ,070 26,003 29,874 32,401 51,165 56,502 78,545 82,933 87,078 1,02, ,520 26,564 30,524 33,111 52,682 58,200 80,845 85,385 89,672 1,05, ,971 27,125 31,175 33,821 54,198 59,899 83,146 87,837 92,265 1,08, ,368 30,118 34,839 37,923 61,072 67,806 92,304 97,844 1,03,075 1,22, ,765 33,110 38,503 42,025 67,945 75,713 1,01,462 1,07,851 1,13,885 1,35, ,904 35,751 41,715 45,610 74,098 82,763 1,09,834 1,16,961 1,23,691 1,48, ,042 38,391 44,927 49,195 80,250 89,812 1,18,206 1,26,070 1,33,497 1,60, ,783 41,794 49,054 53,796 88,445 99,187 1,29,440 1,38,275 1,46,620 1,76, ,525 45,198 53,181 58,397 96,639 1,08,562 1,40,673 1,50,480 1,59,744 1,93, ,038 50,842 60,046 66,061 1,10,365 1,24,294 1,59,304 1,70,761 1,81,584 2,20, ,551 56,485 66,912 73,724 1,24,090 1,40,026 1,77,935 1,91,043 2,03,425 2,48, ,627 64,093 76,177 84,074 1,42,387 1,61,011 2,02,693 2,18,012 2,32,484 2,85, ,703 71,700 85,442 94,423 1,60,683 1,81,996 2,27,451 2,44,982 2,61,543 3,21, ,560 77,717 92,711 1,02,509 1,75,540 1,98,963 2,48,008 2,67,276 2,85,475 3,51, ,418 83,733 99,981 1,10,596 1,90,397 2,15,929 2,68,565 2,89,570 3,09,407 3,81, ,832 90,493 1,08,196 1,19,762 2,07,483 2,35,509 2,91,784 3,14,841 3,36,617 4,15, ,246 97,253 1,16,411 1,28,929 2,24,568 2,55,090 3,15,003 3,40,112 3,63,827 4,50, ,233 1,03,450 1,23,918 1,37,292 2,41,568 2,74,552 3,38,225 3,65,359 3,90,988 4,84, >yrs 90,220 1,09,647 1,31,425 1,45,656 2,58,568 2,94,015 3,61,446 3,90,607 4,18,148 5,18,301 Age Group (Years) 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C ,340 28,469 32,819 35,663 55,876 61,819 85,444 90,334 94,952 1,11, ,634 28,946 33,367 36,257 57,235 63,335 87,542 92,562 97,301 1,14, ,928 29,422 33,915 36,851 58,593 64,851 89,639 94,789 99,651 1,17, ,482 32,498 37,682 41,069 65,625 72,941 99,000 1,05,019 1,10,705 1,31, ,035 35,574 41,448 45,287 72,656 81,030 1,08,361 1,15,249 1,21,758 1,45, ,330 38,297 44,763 48,987 78,965 88,261 1,16,938 1,24,583 1,31,806 1,58, ,625 41,020 48,077 52,688 85,275 95,491 1,25,514 1,33,917 1,41,854 1,70, ,405 44,444 52,230 57,317 93,509 1,04,913 1,36,799 1,46,178 1,55,038 1,87, ,185 47,869 56,383 61,946 1,01,743 1,14,334 1,48,083 1,58,439 1,68,221 2,03, ,698 53,513 63,248 69,609 1,15,469 1,30,066 1,66,714 1,78,721 1,90,063 2,31, ,212 59,157 70,114 77,273 1,29,194 1,45,798 1,85,345 1,99,002 2,11,905 2,58, ,288 66,765 79,380 87,622 1,47,491 1,66,783 2,10,103 2,25,972 2,40,963 2,95, ,364 74,374 88,647 97,972 1,65,787 1,87,769 2,34,861 2,52,941 2,70,021 3,32, ,220 80,389 95,915 1,06,058 1,80,643 2,04,735 2,55,418 2,75,235 2,93,955 3,62, ,076 86,404 1,03,183 1,14,144 1,95,498 2,21,702 2,75,975 2,97,529 3,17,888 3,91, ,490 93,164 1,11,398 1,23,311 2,12,584 2,41,282 2,99,194 3,22,800 3,45,098 4,26, ,904 99,924 1,19,613 1,32,478 2,29,670 2,60,862 3,22,413 3,48,071 3,72,308 4,60, ,892 1,06,122 1,27,120 1,40,841 2,46,669 2,80,325 3,45,634 3,73,319 3,99,468 4,94, >yrs 94,881 1,12,321 1,34,627 1,49,204 2,63,669 2,99,788 3,68,855 3,98,566 4,26,629 5,28,670

9 Age Group (Years) 2A 2A 2A 2A 2A 2A 2A 2A 2A 2A ,125 23,205 26,462 28,588 47,013 51,760 72,784 76,690 80,377 93, ,686 24,894 28,466 30,800 50,964 56,220 78,578 82,902 86,986 1,01, ,247 26,583 30,470 33,012 54,914 60,680 84,372 89,115 93,594 1,09, ,463 30,347 35,056 38,134 63,711 70,769 96,274 1,02,078 1,07,561 1,27, ,680 34,111 39,641 43,257 72,508 80,858 1,08,176 1,15,042 1,21,528 1,45, ,709 37,596 43,847 47,933 80,726 90,229 1,19,624 1,27,442 1,34,826 1,61, ,738 41,081 48,053 52,609 88,944 99,601 1,31,073 1,39,841 1,48,124 1,78, ,829 45,807 53,740 58,923 1,00,249 1,12,473 1,46,957 1,57,014 1,66,512 2,01, ,921 50,534 59,426 65,236 1,11,553 1,25,345 1,62,840 1,74,186 1,84,901 2,23, ,260 57,978 68,412 75,227 1,29,505 1,45,828 1,87,799 2,01,226 2,13,909 2,60, ,599 65,422 77,397 85,219 1,47,457 1,66,311 2,12,758 2,28,266 2,42,916 2,96, ,836 76,146 90,382 99,681 1,73,164 1,95,693 2,48,172 2,66,704 2,84,210 3,47, ,073 86,869 1,03,367 1,14,143 1,98,872 2,25,075 2,83,585 3,05,142 3,25,504 3,99, ,835 96,735 1,15,229 1,27,311 2,22,876 2,52,408 3,17,308 3,41,603 3,64,550 4,47, ,598 1,06,600 1,27,091 1,40,478 2,46,880 2,79,741 3,51,030 3,78,064 4,03,596 4,96, ,02,554 1,16,849 1,39,483 1,54,270 2,72,457 3,08,964 3,86,337 4,16,370 4,44,735 5,47, ,11,510 1,27,097 1,51,874 1,68,061 2,98,034 3,38,187 4,21,644 4,54,676 4,85,874 5,99, ,20,121 1,36,866 1,63,644 1,81,141 3,23,987 3,67,809 4,57,666 4,93,715 5,27,763 6,51, >yrs 1,28,732 1,46,635 1,75,415 1,94,220 3,49,941 3,97,431 4,93,688 5,32,754 5,69,652 7,03,826 Age Group (Years) 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C ,109 26,491 30,422 32,989 53,280 58,877 81,699 86,304 90,654 1,06, ,565 28,065 32,284 35,039 57,010 63,083 87,209 92,205 96,923 1,14, ,020 29,638 34,146 37,089 60,739 67,288 92,719 98,105 1,03,192 1,21, ,341 33,517 38,875 42,372 69,757 77,630 1,04,905 1,11,382 1,17,498 1,39, ,662 37,397 43,603 47,656 78,776 87,973 1,17,090 1,24,660 1,31,805 1,57, ,796 40,998 47,951 52,494 87,213 97,600 1,28,825 1,37,372 1,45,442 1,74, ,931 44,599 52,299 57,332 95,650 1,07,228 1,40,559 1,50,084 1,59,080 1,91, ,048 49,355 58,022 63,686 1,07,010 1,20,163 1,56,514 1,67,334 1,77,555 2,14, ,165 54,110 63,746 70,040 1,18,369 1,33,099 1,72,468 1,84,584 1,96,030 2,37, ,504 61,554 72,730 80,032 1,36,321 1,53,582 1,97,427 2,11,625 2,25,036 2,73, ,843 68,998 81,715 90,023 1,54,274 1,74,065 2,22,386 2,38,667 2,54,043 3,09, ,080 79,723 94,699 1,04,485 1,79,981 2,03,447 2,57,800 2,77,105 2,95,336 3,61, ,317 90,448 1,07,684 1,18,948 2,05,688 2,32,829 2,93,213 3,15,543 3,36,630 4,13, ,079 1,00,312 1,19,546 1,32,115 2,29,692 2,60,162 3,26,936 3,52,003 3,75,676 4,61, ,842 1,10,176 1,31,409 1,45,283 2,53,697 2,87,495 3,60,658 3,88,462 4,14,722 5,10, ,05,798 1,20,424 1,43,800 1,59,074 2,79,273 3,16,718 3,95,965 4,26,770 4,55,863 5,61, ,14,754 1,30,673 1,56,191 1,72,866 3,04,850 3,45,941 4,31,273 4,65,077 4,97,003 6,13, ,23,364 1,40,442 1,67,963 1,85,945 3,30,804 3,75,563 4,67,294 5,04,114 5,38,890 6,65, >yrs 1,31,973 1,50,211 1,79,735 1,99,024 3,56,758 4,05,184 5,03,316 5,43,152 5,80,778 7,17,601 Age Group (Years) 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C ,734 30,597 35,396 38,531 61,100 67,792 92,632 98,136 1,03,335 1,22, ,061 32,021 37,073 40,374 64,549 71,670 97,775 1,03,633 1,09,166 1,29, ,388 33,445 38,750 42,218 67,998 75,548 1,02,918 1,09,130 1,14,997 1,36, ,838 37,474 43,663 47,707 77,297 86,220 1,15,469 1,22,809 1,29,743 1,54, ,289 41,503 48,577 53,197 86,595 96,891 1,28,021 1,36,488 1,44,488 1,73, ,552 45,253 53,110 58,242 95,317 1,06,844 1,40,122 1,49,605 1,58,562 1,91, ,815 49,003 57,643 63,287 1,04,038 1,16,797 1,52,223 1,62,721 1,72,636 2,08, ,966 53,796 63,412 69,693 1,15,468 1,29,816 1,68,269 1,80,072 1,91,219 2,31,753

10 ,117 58,590 69,181 76,100 1,26,898 1,42,834 1,84,315 1,97,423 2,09,802 2,54, ,455 66,034 78,165 86,092 1,44,850 1,63,316 2,09,274 2,24,463 2,38,809 2,90, ,793 73,478 87,150 96,083 1,62,802 1,83,797 2,34,232 2,51,503 2,67,817 3,27, ,031 84,203 1,00,135 1,10,545 1,88,510 2,13,181 2,69,648 2,89,941 3,09,111 3,78, ,269 94,928 1,13,119 1,25,007 2,14,217 2,42,564 3,05,063 3,28,379 3,50,405 4,30, ,031 1,04,792 1,24,982 1,38,175 2,38,221 2,69,897 3,38,784 3,64,840 3,89,451 4,78, ,00,792 1,14,656 1,36,844 1,51,343 2,62,226 2,97,230 3,72,505 4,01,301 4,28,497 5,27, ,09,748 1,24,905 1,49,235 1,65,134 2,87,802 3,26,452 4,07,813 4,39,607 4,69,636 5,78, ,18,704 1,35,153 1,61,626 1,78,925 3,13,379 3,55,673 4,43,122 4,77,913 5,10,774 6,30, ,27,315 1,44,922 1,73,398 1,92,005 3,39,333 3,85,295 4,79,142 5,16,952 5,52,663 6,82, >yrs 1,35,926 1,54,691 1,85,170 2,05,084 3,65,286 4,14,917 5,15,162 5,55,991 5,94,552 7,34,778 2,00,000 3,00,000 4,00,000 5,00,000 7,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C ,004 35,526 41,383 45,212 70,479 78,508 1,05,578 1,12,181 1,18,420 1,41, ,175 36,767 42,836 46,801 73,581 81,986 1,10,273 1,17,186 1,23,717 1,47, ,345 38,009 44,289 48,391 76,683 85,465 1,14,968 1,22,191 1,29,014 1,53, ,952 42,220 49,427 54,135 86,329 96,535 1,27,968 1,36,364 1,44,293 1,73, ,559 46,431 54,565 59,878 95,974 1,07,606 1,40,969 1,50,536 1,59,573 1,92, ,979 50,364 59,324 65,176 1,05,041 1,17,959 1,53,517 1,64,144 1,74,181 2,10, ,398 54,296 64,082 70,474 1,14,107 1,28,312 1,66,065 1,77,751 1,88,788 2,28, ,587 59,135 69,907 76,944 1,25,624 1,41,430 1,82,224 1,95,226 2,07,507 2,52, ,775 63,975 75,731 83,413 1,37,142 1,54,548 1,98,383 2,12,700 2,26,225 2,75, ,113 71,419 84,717 93,406 1,55,093 1,75,029 2,23,340 2,39,740 2,55,231 3,11, ,451 78,863 93,703 1,03,399 1,73,043 1,95,511 2,48,297 2,66,781 2,84,238 3,47, ,689 89,587 1,06,687 1,17,861 1,98,752 2,24,895 2,83,713 3,05,219 3,25,531 3,99, ,927 1,00,310 1,19,672 1,32,323 2,24,461 2,54,278 3,19,128 3,43,657 3,66,825 4,51, ,690 1,10,175 1,31,535 1,45,490 2,48,465 2,81,611 3,52,850 3,80,118 4,05,871 4,99, ,05,452 1,20,041 1,43,397 1,58,658 2,72,470 3,08,944 3,86,573 4,16,579 4,44,917 5,47, ,14,408 1,30,289 1,55,788 1,72,448 2,98,046 3,38,165 4,21,880 4,54,885 4,86,057 5,99, ,23,364 1,40,538 1,68,179 1,86,238 3,23,623 3,67,387 4,57,187 4,93,190 5,27,197 6,50, ,31,974 1,50,307 1,79,950 1,99,318 3,49,575 3,97,009 4,93,207 5,32,229 5,69,085 7,03, >yrs 1,40,584 1,60,076 1,91,721 2,12,397 3,75,527 4,26,630 5,29,227 5,71,269 6,10,973 7,55,358 Age Group (Years) 3,367 4,186 5,072 5,650 7,970 9,091 11,125 12,044 12,912 16,069 All premium rates are inclusive of 2 year premium discount, service tax and applicable cess. A family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policy under individual sum insured plan Loading We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). The maximum risk loading applicable for an individual shall not exceed above 100% per diagnosis / medical condition and an overall risk loading of over 150% per person. These loadings are applied from commencement date of the policy including subsequent renewal(s) with us or on the receipt of the request of increase in sum insured (for the increased sum insured). Please Note. 1. Premium rates and policy terms and conditions are for standard healthy individuals. These may change post underwriting of proposal based on medical tests (where applicable) and information provided on the proposal form. Please visit our nearest branch to refer to our underwriting guidelines, if required. Premium rates are subject to change with prior approval from IRDA. 2. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law. AMHI/MA/H/0002/0122/072014/P CT/AMHP/BR/V0.01/032015

11 Apollo Munich HEALTH PLAN For Citibank customers Application Number. Specified Person Name Code Location This is an application for Insurance. Every Information this application seeks is important. Please read all questions and answer them carefully. You must provide complete and correct information. Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy even if it is issued. It is not obligatory for us to accept any risk or issue policy to anyone. Regulations mandate that the coverage can incept only after we have received the full amount of premium and have explicitly accepted the risk. We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). Please note that We will issue Policy only after getting Your consent in case of risk loading. We are under no obligation to accept any proposal for insurance. If We accept a proposal for insurance, it shall be subject to the Policy terms and conditions and We shall have no liability to make any payment under the Policy 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 is not realised, or non-fulfillments of Pre Policy Checkup and/or additional information requested by us. To be filled by the Bank Customer Segment: CPC Citigold Citibanking Suvidha Others ( please mention) To be filled by the Customer Please note all sections are mandatory (except for the sections marked*) 1. PROPOSER DETAILS Name: (Mr./Ms./Mrs.) First Name Middle Name Last Name Address Pin Code District/City State id Date of Birth D D M M Y Y Y Y STD Code Landline Mobile Annual Income Marital Status Nationality *Id Proof Type : PAN Passport Driving License Voter s Card If Other, please specify *Id Proof No. Please circle against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the listed titles below, please tick against all the applicable heads. Head of State or of Government / Senior Politician / Senior Government / Judicial / Military Officer / Senior Executive of State-Owned Corporation / Important Political Party Official 2. PLAN DETAILS Plan Name: Apollo Munich Health Plan for Citibank customers- Silver Gold Platinum Type of Policy: Individual Floater Policy Period: 1 Year 2 Year 3. PROPOSED INSURED(S) DETAILS S.No Name of the Insured person Relationship to Policyholder Gender Date of Birth Height (cms) Weight (kgs) Note: The insured and his family cannot select sum insured across variants in a single policy/application ren aged between 91 days and 25 years can be covered. If the child age is between 91 days to 5 years, please confirm whether one of the parent is getting covered in the plan Yes No Sum insured* ( in Rs.) Total premium including tax & cess Deduct 5% family discount if 2 member and 10% if 3 or more member are covered in case of individual plan. The discount may change if there is a change in the number of members covered in the policy at renewal. Total premium payable Premium ( in Rs.) * Family Floater policy will have same Sum Insured for all members 4. NOMINEE DETAILS In the event of the death of an Insured Person any payment due under the Policy shall become payable to the nominee in accordance with the policy terms and conditions. The nominee must be an immediate relative of the Proposer. The nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself. Nominee Name Relationship to Proposer *5. PHOTOGRAPHS Please paste the photographs in sequence [Insured 1, Insured 2, Insured 3, Insured 4, Insured 5 and Insured 6] as specified in section 3 of details of proposed to be insured Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h) Photo 28mm(w) x 30mm(h)

12 6. MEDICAL QUESTIONNAIRE (Medical & Life Style Information (Declaration)) Have you or any other member(s) proposed to be insured under this policy ever suffered from or are suffering from any of the following: Insured 1 Insured 2 Insured 3 Insured 4 Insured 5 Insured 6 Arthritis, disorders of the spinal cord or vertebral column for example slipped disc. Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Circulatory disorder, heart condition, paralysis of any kind, Haematological (blood) disorder Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Tumour or cancer of any kind, Diabetes, high blood pressure, allergies Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Disorders of the stomach / large or small intestine, hernia of any kind, haemorrhoids Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Nervous disorder, fainting episode, blackouts, fits, mental condition Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Respiratory disorder, urinary disorder, varicose veins Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Any diseases or injury requiring surgical or medical treatment Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Have you or any other member proposed to be insured under this policy sought medical advice in past 10 years or been advised or awaiting any treatment medical or surgical due to any of the diseases/conditions listed above or otherwise or attended follow up for any disease / condition / ailment/ injury / addiction (except Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N for infrequent common illness for example common cold, loose motions, cough and cold, headaches, acidity)? Does your or any of the person proposed under this policy s occupation or nature of job involve working in military or paramilitary forces, security forces, merchant navy or shipping, mines, electrical, aviation (flying), Oil or natural gas production or refining, explosive units or chemical industry or metal industry; working at Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N heights (above or underground/sea level); handling of heavy machinery or hazardous materials; driving of heavy motor vehicles or significant manual labor? Is any of the insured pregnant? If yes please mention the expected date of delivery D D M M Y Y Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N To be filled if any of the answers to above questions is answered as Yes Insured Person Name and details of Illness/ Medicine/Test/Surgery/Condition Diagnosis Date or Date of last consultation Details if inpatient/ outpatient was given To provide additional information for other insured member(s), please provide details in above format on an extra sheet duly signed. 7. PORTABILITY I want to avail portability benefit? Yes No (if yes, please fill the portability form and submit portability documents) 8. EXISTING/PREVIOUS INSURER DETAILS Policyholder Name Policy No./Application Period of Insurance Sum Insured No. Insurer From To (Rs.) D D M M Y Y D D M M Y Y Claims lodged during the preceding years 9. PREMIUM PAYMENT DETAILS Instrument (Credit Card,Bank Account) Instrument Number Instrument Date Name of Payor Bank Name IFSC Code Amount ( Rs.) NA NA Citibank In case Premium is more than Rs.50,000, please provide PAN details. Section 41 of Insurance Act 1938 (Prohibition of rebates): 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 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 prospectus or tables of the insurers. Any person making default in complying with the provision of this section shall be punishable with fine which may extend to five hundred rupees. 10. EXCLUSIONS Following is an outline of the main exclusions below. Please refer policy wordings for detailed exclusions before purchasing this policy. Any illness/ disease/ injury pre-existing before the inception of the policy for the first 2/3 years, Non-allopathic treatment,, cosmetic aesthetic, dental treatment and obesity-related treatment, Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury, Medical expenses incurred during the first 30 days of inception of the policy, except those arising out of accidents, 2 years waiting period for the specified illnesses/ surgeries. This exclusion doesn t apply for subsequent renewals without a break, Congenital disease, genetic disorders, stem cell implantation, War, riot, strike, nuclear weapons induced hospitalisation, any hazardous or dangerous or adventurous activities, Psychiatric, mental or nervous disorders, Parkinson and Alzheimer s disease, measures primarily for diagnostic, X-ray or laboratory examinations which are not consistent with or incidental to the diagnosis and treatment, general debility or exhaustion, any treatment that is not of a reasonable cost, not medically necessary; drugs or treatments which are not supported by a prescription, crutches or any other external appliance and/or device used for diagnosis or treatment. 11. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS TO BE INSURED I/ We 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/We am/are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of insurance policy, is subject to the Board approved underwriting policy of the Insurance Company and that the policy will come into force only after full receipt of the premium chargeable. I/ We further declare that I/We 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. I/ We declare and consent to the company seeking medical information from any hospital who at any time has attended on the life to be insured/proposer or from any past or present employer concerning anything which affects the physical and mental health of the life to be assured/proposer and seeking information from any Insurance company to which an application for insurance on the life to be assured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement. I/ We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/ or Regulatory Authority. I understand that the AMHI may terminate the policy immediately, on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by any Insured Person or anyone acting on policy holder s behalf or on behalf of an Insured Person upon 30 days notice by sending an endorsement to Insured Person s address shown in the Schedule without refund of premium. I confirm that I have read the brochure and understood all the terms and conditions, coverage s, and exclusion (related to: pre-existing diseases, waiting period and exclusion) and I accept them. I understand that Citibank N.A. will earn 15% as commission on this policy in their capacity as the licensed Corporate Agent of Apollo Munich Heath Insurance Company Limited. Signature of Proposer: Date: Time: Place: For detailed terms and conditions, please refer insurance policy document. 12. VERNACULAR DECLARATION Certification in case the proposer has signed in vernacular (to be witnessed by someone other than agent/employee of the company): Name of Proposer: The content of this form and its particulars have been explained by me in vernacular to the proposer who has understood and confirmed the same. Signature of Proposer: Signature of the witness: Date: Place Name of the witness: Apollo Munich Health Insurance Co. Ltd. 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana. Corp. Office : 1st Floor, SCF -19, Sector - 14, Gurgaon , Haryana. Regd. Office : Apollo Hospitals Complex, Jubilee Hills, Hyderabad , Andhra Pradesh. Toll Free: citicare@apollomunichinsurance.com Website: Citibank is an IRDA licensed corporate agent (CA license No.) of Apollo Munich Health Insurance Company Limited ( AMHI ). This Insurance policy is underwritten by AMHI. Participation by Citibank customers shall purely be on voluntary basis. For more details on terms and conditions please read sales brochure carefully before concluding a sale. Insurance is the subject matter of solicitation IRDA Registration Number Corporate Identity Number: U66030AP2006PLC AMHI/PR/H/0034/0122/072014/P