UNBELIEVABLE. UNBELIEVABLE. The unbelievable health plan. A factory worker from Malaysia sticks metal objects magnetically to his body.

Transcription

1 For Citibank customers only The unbelievable health plan Guan from China inflates balloons using just his ears. UNBELIEVABLE. A factory worker from Malaysia sticks metal objects magnetically to his body. UNBELIEVABLE. A contortionist from America packs all of herself into a suitcase in just 5.43 seconds. Points to Remember Maximum Age : The maximum entry age in the policy is 65 years. There is no maximum cover ceasing age in this policy. Minimum Age : The minimum entry age is 91 days. Children between 91 days and 5 years can be insured if either parent is getting insured under this policy. 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. 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. This policy can be issued to an individual and/or family. A maximum of 6 members can be added in a single policy, whether on an Individual or Family floater basis. 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. The Sum Insured of the dependent insured members should be equal to or less than the Sum Insured of the primary insured member. In case where two or more children are covered, the Sum Insured for all the children must be same. Sum insured of Dependent Parents /Parents-in-law must be the same.

2 FEATURES and BENEFITS Optima Restore-Individual Basic Sum Insured per Insured Person per Policy Year (Rs. in Lakh) 3.00, 5.00, 10.00, ,25.00, a) In-patient Treatment Covered Covered 1b) Pre-Hospitalization Covered, upto 60 Days Covered, upto 60 Days 1c) Post-Hospitalization Covered, upto 180 Days Covered, upto 180 Days 1d) Day Care Procedures Covered Covered 1e) Domiciliary Treatment Covered Covered 1f) Organ Donor Covered Covered 1g) Emergency Ambulance Upto Rs.2,000 per Hospitalisation Upto Rs.2,000 per Hospitalisation 1h) Daily Cash for choosing Shared Accommodation Rs.800 per day, Maximum Rs.4,800 Rs.1000 per day, Maximum Rs.6,000 1i) E-Opinion in respect of a Critical Illness Covered Covered 2) Restore Benefit Equal to 100% of Basic Sum Insured Equal to 100% of Basic Sum Insured 3) Health Checkup Not Covered Upto 1% of Sum Insured subject to a Maximum of Rs.10,000 per Insured Person, only once at the end of a block of every continuous two policy years 4) Multiplier Benefit Bonus of 50% of the Basic Sum Insured for every claim free year, maximum upto 100%. In case of claim, bonus will be reduced by 50% of the Basic Sum Insured at the time of renewal Bonus of 50% of the Basic Sum Insured for every claim free year, maximum upto 100%. In case of claim, bonus will be reduced by 50% of the Basic Sum Insured at the time of renewal Optima Restore- Family Floater Basic Sum Insured per Policy per Policy Year (Rs. in Lakh) 3.00, 5.00, 10.00, ,25.00, a) In-patient Treatment Covered Covered 1b) Pre-Hospitalization Covered, upto 60 Days Covered, upto 60 Days 1c) Post-Hospitalization Covered, upto 180 Days Covered, upto 180 Days 1d) Day Care Procedures Covered Covered 1e) Domiciliary Treatment Covered Covered 1f) Organ Donor Covered Covered 1g) Emergency Ambulance Upto Rs.2,000 per Hospitalisation Upto Rs.2,000 per Hospitalisation 1h) Daily Cash for choosing Shared Accommodation Rs.800 per day, Maximum Rs.4,800 Rs.1000 per day, Maximum Rs.6,000 1i) E-Opinion in respect of a Critical Illness Covered Covered 2) Restore Benefit Equal to 100% of Basic Sum Insured Equal to 100% of Basic Sum Insured 3) Health Checkup Not covered Upto 1% of Sum Insured per Policy subject to a Maximum of Rs. 10,000 per policy, only once at the end of a block of every continuous two policy years. 4) Multiplier Benefit Bonus of 50% of the Basic Sum Insured for every claim free year, maximum upto 100%. In case of claim, bonus will be reduced by 50% of the Basic Sum Insured at the time of renewal Bonus of 50% of the Basic Sum Insured for every claim free year, maximum upto 100%. In case of claim, bonus will be reduced by 50% of the Basic Sum Insured at the time of renewal

3 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: Optima Restore 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 preauthorization 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) Major Exclusions Any treatment within first 30 days of cover except any accidental injury. Any pre existing diseases/conditions will be covered after a waiting period of 3 years. 2 year exclusion for specific diseases like cataract, hernia,hysterectomy, joint replacement etc Expenses arising from HIV or AIDS and related diseases Pregnancy, dental treatment, external aids and appliances 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 A man from a little town in Morocco snacks on anything. Even nails. UNBELIEVABLE. 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. Health checkup This benefit is effective only if mentioned in the Schedule of Benefits. If You have maintained an Optima Restore Policy with Us for the period of time mentioned in the Schedule of Benefits without any break, then at the end of each block of continuous years (as mentioned in the Schedule of benefits) We will pay upto the percentage (mentioned in the Schedule of Benefits) of the Sum Insured for this Policy Year or the subsequent Policy Years (whichever is lower) towards the cost of a medical check-up for those Insured Persons who were insured for the number of previous Policy Years mentioned in the Schedule. Plan Optima Restore Individual Optima Restore Family Sum Insured- 20,25,50 Lacs Upto 1% of Sum Insured subject to a Maximum of Rs.10,000 per Insured Person, only once at the end of a block of every continuous two policy years Upto 1% of Sum Insured per Policy subject to a Maximum of Rs. 10,000 per policy, only once at the end of a block of every continuous two policy years

4 Terms of Renewal Lifelong 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. Maximum Age - There is no maximum cover ceasing age on renewal in this policy. Waiting Period - The waiting periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of your Optima Restore 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 atleast 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. Basic Sum Insured Enhancement - Sum Insured can be enhanced only at the time of renewal subject to no claim having been lodged/paid under the Policy. If the insured increases the Sum Insured one grid up, no fresh medicals shall be required. In case where the Sum Insured increase is more than one grid up, the case shall be subject to medicals. In case of increase in the Sum Insured, waiting period will apply afresh for the amount by which the Sum Insured has been enhanced. However, the quantum of increase shall be at the discretion of the company. 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 as per portability guidelines issued by IRDA. Child dependent after attaining the age of 25 years will be offered coverage under separate individual policy with all continuity benefits. Portability OptimaRESTORE, offers you easy portability, so if you are insured under another Insurer s health insurance policy you can transfer to Apollo Munich with all your accrued benefits after due allowances for waiting periods and enjoy all the unbelievable benefits of OptimaRESTORE. Tax Benefit The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act. Discounts Family discount of 10% if 2 or more family members are covered under Optima Restore Individual Sum Insured Plan. An additional 7.5% discount is offered on the premium if you choose a 2 year policy. 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.

5 Termination 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. 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 Apollo Munich Health Insurance Company limited (Regn. No. 131) under the composite license number This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company 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 Insurance Act 1938 as amended by Insurance Laws Amendment Act, 2015 (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 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 insurers. 2). Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees. 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 Apollo Munich Health Insurance Co. Ltd. 2nd & 3rd Floor, ilabs Centre, Plot No , Udyog Vihar, Phase-III, Gurgaon , Haryana.

6 TARIFF SHEET Annual Individual Premium ( Inclusive of Service tax) Age Group 1A 1A 1A 1A 1A 1A 1A ,885 6,197 7,144 8,563 10,324 11,204 14, ,836 7,404 9,861 11,820 14,250 15,465 19, ,604 8,379 11,382 13,642 16,447 17,850 22, ,660 12,256 16,935 20,298 24,471 26,557 34, ,214 15,497 21,694 26,002 31,349 34,022 43, ,768 20,006 28,449 34,099 41,110 44,615 57, ,897 27,782 40,129 48,099 57,988 62,933 80, ,215 38,335 55,769 66,845 80,589 87,462 1,12, ,503 46,313 68,045 81,560 98,330 1,06,714 1,37, ,803 55,575 82,558 98,954 1,19,300 1,29,472 1,66,464 > 80 50,373 63,912 96,886 1,16,128 1,40,006 1,51,944 1,95,357 Annual Family Floater Premium ( inclusive of service tax) Age Group 1A + 1C 1A + 1C 1A + 1C 1A + 1C 1A + 1C 1A + 1C 1A + 1C ,529 9,551 12,337 14,787 17,827 19,347 24, ,160 10,352 13,657 16,369 19,736 21,418 27, ,353 14,404 19,410 23,264 28,047 30,439 39, ,044 17,818 24,369 29,209 35,215 38,217 49, ,632 22,370 31,174 37,366 45,048 48,890 62, ,761 30,146 42,854 51,365 61,926 67,206 86, ,078 40,699 58,495 70,112 84,528 91,736 1,17, ,367 48,677 70,771 84,827 1,02,268 1,10,988 1,42, ,666 57,939 85,283 1,02,220 1,23,237 1,33,746 1,71,960 > 80 52,237 66,276 99,612 1,19,396 1,43,944 1,56,219 2,00,852 Age Group 1A + 2C 1A + 2C 1A + 2C 1A + 2C 1A + 2C 1A + 2C 1A + 2C ,705 12,312 15,519 18,601 22,426 24,339 31, ,160 12,891 16,582 19,876 23,963 26,006 33, ,530 17,165 22,593 27,080 32,647 35,431 45, ,395 20,802 27,809 33,332 40,185 43,612 56, ,028 25,411 34,679 41,566 50,112 54,385 69, ,157 33,187 46,358 55,565 66,990 72,702 93, ,474 43,740 61,999 74,312 89,591 97,231 1,25, ,762 51,717 74,276 89,027 1,07,331 1,16,484 1,49, ,062 60,980 88,787 1,06,420 1,28,301 1,39,242 1,79,026 > 80 54,633 69,315 1,03,116 1,23,595 1,49,008 1,61,714 2,07,918

7 Age Group 1A + 3C 1A + 3C 1A + 3C 1A + 3C 1A + 3C 1A + 3C 1A + 3C ,913 13,846 17,287 20,721 24,981 27,111 34, ,271 14,300 18,208 21,824 26,311 28,555 36, ,738 18,699 24,361 29,199 35,202 38,204 49, ,702 22,460 29,720 35,623 42,947 46,609 59, ,359 27,099 36,625 43,899 52,926 57,438 73, ,488 34,875 48,305 57,898 69,803 75,755 97, ,805 45,428 63,946 76,646 92,405 1,00,284 1,28, ,093 53,406 76,222 91,361 1,10,145 1,19,537 1,53, ,394 62,668 90,734 1,08,754 1,31,115 1,42,295 1,82,951 > 80 55,964 71,005 1,05,062 1,25,929 1,51,821 1,64,766 2,11,843 Age Group 1A + 4C 1A + 4C 1A + 4C 1A + 4C 1A + 4C 1A + 4C 1A + 4C ,136 16,667 20,537 24,617 29,678 32,210 41, ,494 17,121 21,458 25,721 31,008 33,653 43, ,961 21,520 27,611 33,095 39,899 43,302 55, ,925 25,281 32,970 39,519 47,644 51,707 66, ,582 29,919 39,875 47,796 57,622 62,536 80, ,711 37,695 51,555 61,795 74,500 80,853 1,03, ,028 48,248 67,196 80,542 97,102 1,05,382 1,35, ,316 56,226 79,472 95,257 1,14,841 1,24,635 1,60, ,617 65,488 93,984 1,12,650 1,35,812 1,47,393 1,89,504 > 80 58,187 73,825 1,08,313 1,29,825 1,56,517 1,69,865 2,18,397 Age Group 1A + 5C 1A + 5C 1A + 5C 1A + 5C 1A + 5C 1A + 5C 1A + 5C ,359 19,487 23,787 28,514 34,374 37,308 47, ,717 19,941 24,708 29,617 35,705 38,751 49, ,184 24,340 30,861 36,992 44,596 48,400 62, ,148 28,101 36,220 43,416 52,341 56,805 73, ,805 32,740 43,125 51,692 62,319 67,634 86, ,934 40,516 54,806 65,691 79,197 85,951 1,10, ,251 51,069 70,446 84,439 1,01,799 1,10,480 1,42, ,539 59,046 82,722 99,154 1,19,538 1,29,733 1,66, ,840 68,309 97,234 1,16,547 1,40,508 1,52,491 1,96,058 > 80 60,410 76,646 1,11,563 1,33,722 1,61,214 1,74,963 2,24,951 Age Group 2A 2A 2A 2A 2A 2A 2A ,170 10,366 13,805 16,548 19,950 21,651 27, ,753 12,374 16,768 20,099 24,232 26,298 33, ,875 17,603 24,287 29,110 35,095 38,087 48, ,491 22,192 31,005 37,162 44,802 48,622 62, ,306 28,301 40,121 48,090 57,977 62,920 80, ,039 38,112 54,845 65,738 79,255 86,013 1,10, ,382 52,504 76,230 91,370 1,10,156 1,19,548 1,53, ,407 65,223 95,594 1,14,579 1,38,138 1,49,917 1,92, ,156 78,860 1,16,804 1,40,002 1,68,787 1,83,180 2,35,517 > 80 72,202 91,607 1,38,147 1,65,584 1,99,629 2,16,651 2,78,552

8 Age Group 2A + 1C 2A + 1C 2A + 1C 2A + 1C 2A + 1C 2A + 1C 2A + 1C ,862 12,513 16,281 19,515 23,527 25,534 32, ,309 14,347 19,044 22,826 27,520 29,866 38, ,567 19,751 26,762 32,077 38,672 41,970 53, ,321 24,513 33,679 40,369 48,669 52,818 67, ,169 30,665 42,847 51,356 61,916 67,195 86, ,903 40,477 57,571 69,005 83,193 90,287 1,16, ,246 54,868 78,955 94,636 1,14,095 1,23,823 1,59, ,271 67,587 98,319 1,17,846 1,42,076 1,54,192 1,98, ,019 81,224 1,19,529 1,43,268 1,72,726 1,87,454 2,41,012 > 80 74,066 93,971 1,40,872 1,68,851 2,03,568 2,20,926 2,84,048 Age Group 2A + 2C 2A + 2C 2A + 2C 2A + 2C 2A + 2C 2A + 2C 2A + 2C ,038 15,274 19,464 23,330 28,126 30,525 39, ,308 16,886 21,969 26,333 31,747 34,454 44, ,743 22,512 29,944 35,892 43,271 46,961 60, ,673 27,497 37,120 44,491 53,639 58,213 74, ,565 33,705 46,350 55,556 66,978 72,690 93, ,298 43,516 61,076 73,205 88,257 95,782 1,23, ,642 57,907 82,460 98,836 1,19,157 1,29,318 1,66, ,666 70,626 1,01,824 1,22,046 1,47,140 1,59,687 2,05, ,415 84,264 1,23,033 1,47,468 1,77,789 1,92,950 2,48,078 > 80 76,462 97,011 1,44,376 1,73,051 2,08,631 2,26,421 2,91,113 Age Group 2A + 3C 2A + 3C 2A + 3C 2A + 3C 2A + 3C 2A + 3C 2A + 3C ,698 18,648 23,354 27,992 33,747 36,625 47, ,754 19,988 25,545 30,618 36,913 40,062 51, ,403 25,886 33,834 40,554 48,892 53,061 68, ,548 31,145 41,324 49,531 59,714 64,807 83, ,494 37,421 50,633 60,689 73,167 79,407 1,02, ,227 47,231 65,358 78,339 94,446 1,02,499 1,31, ,570 61,624 86,743 1,03,969 1,25,346 1,36,035 1,74, ,595 74,343 1,06,107 1,27,180 1,53,329 1,66,404 2,13, ,344 87,980 1,27,316 1,52,602 1,83,978 1,99,666 2,56,713 > 80 79,390 1,00,726 1,48,659 1,78,184 2,14,820 2,33,138 2,99,748 Age Group 2A + 4C 2A + 4C 2A + 4C 2A + 4C 2A + 4C 2A + 4C 2A + 4C ,921 21,468 26,604 31,888 38,444 41,723 53, ,977 22,808 28,795 34,515 41,610 45,160 58, ,626 28,706 37,084 44,451 53,589 58,159 74, ,771 33,965 44,574 53,427 64,411 69,905 89, ,717 40,241 53,883 64,586 77,864 84,505 1,08, ,450 50,052 68,609 82,235 99,142 1,07,597 1,38, ,793 64,444 89,993 1,07,866 1,30,043 1,41,133 1,81, ,818 77,163 1,09,357 1,31,076 1,58,026 1,71,502 2,20, ,567 90,800 1,30,566 1,56,498 1,88,675 2,04,765 2,63,267 > 80 81,613 1,03,546 1,51,910 1,82,081 2,19,517 2,38,236 3,06,302 The premium mentioned is annual premium. All premiums are inclusive of service tax and applicable cess A family discount of 10% will apply if 2 or more family members are covered in the same policy under individual sum insured plan

9 2 YEAR PREMIUM 2 Year Premium ( Inclusive of Service Tax) SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A 1A 1A 1A 1A 1A 1A >yrs Year Premium -Family Floater Premiums ( inc tax) SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C >yrs

10 SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C 1A+2C >yrs SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C 1A+3C >yrs

11 SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C 1A+4C >yrs SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C 1A+5C >yrs

12 SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 2A 2A 2A 2A 2A 2A 2A >yrs SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C 2A+1C >yrs

13 SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C 2A+2C >yrs SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C 2A+3C >yrs

14 SI in INR 3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 Age Group 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C 2A+4C >yrs All premium rates are inclusive of 2 year premium discount, service tax and applicable cess. A family discount of 10% will apply if 2 or more family members are covered in the same policy under individual sum insured plan Loadings 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. CT/OR/BR/V0.02/ AMHI/MA/H/0002/0129/112014/P 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 a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. 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/M/F15/005

15 For Citibank customers only The unbelievable health plan Proposal Number. This proposal will be the basis of any insurance policy that We may issue. You must disclose all facts relevant to all persons proposed to be insured that may affect Our decision to issue a policy or its price, terms, conditions and exclusions. Non-compliance may result in avoidance of the Policy. If there is insufficient space for You to provide information, whether as requested or otherwise, please attach a separate sheet. If You are in any doubt, please seek advice of Your insurance advisor. 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 premium is not received by Us in full and in time, or is not realised, or non-fulfillments of Pre Policy Checkup. 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 Coverage: Individual Floater Policy Period: 1 Year 2 Year 3. PROPOSED INSURED(S) DETAILS S.No Name of the Insured person Relationship to Policyholder Note: Children 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 Gender Date of Birth Height (cms) Weight (kgs) Sum insured* ( in Rs.) Total premium including tax & cess Deduct 10% family discount if 2 or more members are covered in case of individual plan. Total premium payable * 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 Premium *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 ( in Rs.) 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)

16 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 as amended by Insurance Laws Amendment Act, 2015 (Prohibition of Rebates): 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 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 insurers. Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees. 10. EXCLUSIONS The following is an outline of the main exclusions under the policy. For more details on the exclusions and the waiting periods please refer to the policy wordings before purchasing this policy. Waiting Periods - 30 days waiting period in the first year and is not applicable in subsequent renewals. 2 years waiting period for the specified illnesses/ surgeries. 3 years waiting period for Pre-existing conditions. War or any act of war, riot,strike; Any Insured Person committing or attempting to commit a breach of law with criminal intent, or intentional self injury or attempted suicide while sane or insane. Any Insured Person s participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies. Treatment of Obesity and any weight control program. Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the attending Medical Practitioner for reconstruction following an Accident, Cancer or Burns. Congenital internal or external diseases, defects or anomalies, genetic disorders. Stem cell therapy or surgery, or growth hormone therapy. Venereal disease, sexually transmitted disease or illness; AIDS (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human Immunodeficiency Virus) including but not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS Related Complex), Lymphomas in brain, Kaposi s sarcoma, tuberculosis. Pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy in relation to in-patient only. Any specific timebound or lifetime exclusion(s) applied by Us and specified in the Schedule and accepted by the insured. The costs of any procedure or treatment by any person or institution that We have told You (in writing) is not to be used at the time of renewal or at any specific time during the policy period. 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. SPECIFIED PERSON/AGENT`S DECLARATION I, (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorised 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 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 favour 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. Signature of the Specified Person/Agent Specified Person Code Date: Place: 13. VERNACULAR DECLARATION (to be filled only if the proposer has signed in vernacular) 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: AMHI/PR/H/0013/0129/112014/P 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 a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. 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: U66030AP2006PLC051760