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aIcICICLombard Enrollment Form No.:
Nibhaye Vaade Enrollment Form - Income Protect

GUIDELINES FOR COMPLETION OF THE FORM (To be filled by the proposer)

Insurance is a contract of Utmost Good Faith requiringtheProposer not onlyto disclose allmaterial facts, but also
not tosuppress any material facts.
"A material fact willmean and include allimportant, essential and relevant information pertaining to the questions
raised below herein,that is likely to influence the Company's acceptance or assessment of the proposal.
The Policy shall become void at the option of lnsurer, in the event of any untrue or incorrect statement,
misrepresentation, non-description or non-disclosure in any material particular in this form/personal statement,
declaration and connected documents or any material information having been withheld by the Proposer or any one
acting on his behalf. Kindly contact the Company's Offices or Agents for any doubts or clarifications on the
enrollment form.
Note: The liability of the company does not commence until this prop0sal has been accepted and premium is duly
received by the company.
VWe hereby agree and confirm that if the amount realised by the insurer is less than the premium payable for sum
insured proposed for insurance or scope of cover desired by me, the application shallbe considered for acceptance
for a reduced sum insured appropriate to the premium realised by the insurer and the poljcy shall finalised and
issuedaccordingly.
Date:
JJJJJJ Place: JJJJJJJJJJJApplicantMemtas
Signature. Begun
CUSTOMER INFORMATION - PART A
The application forn is to be filled in CAPITALLETTERS by the Proposer. Please answer all questions fly and correctly. Where any
question does not apply,please mention clearly the question is not applicable.
PROPOSER DETAILS

Name of the Propaser Female

Gender: Male
Mi JiM Third
TAZJBEGUM
gender
JJJJJJJJ
Mailing Address of Proposer:
JJJJJJJJJJJJJ
JJJJJJJJJJJJJJJJ JJJJJJJJJJJ.
JJJJJJJJJJJJJJJJJJ_JJJJJ Pincode:
Mobile No.: JJJJJJJJ
Ermail ID:

PANNO.: JJJJJJJJJ AadhaarNo.: JJJJJJJJ_J

Are you or any of the proposed applicantsa PEP* or a close relative of a PEP*? Yes NoJIfyes, please give details:
*Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in aforeign country, e.g. Heads of States/
Goveraments, senior paliticians, seniar govarnumantVíudicial/miltary officers, senior executives af state-owned corparations, important palitical partyofficials, etc.
PROSPECT DETAILS
SECTION l: (f Insured and prospect are same then skip SECTION Tand move toSECTION I)
Name of the Prospect: Mr/ Mrs./ Ms./ Dr.
Gender: Male Female Third gender
JJJJJJJJJJJJJJJJJJJJ
Mobile No.: JJJJJJJJJJEmail ID:
Nominee Name:
Relationship of Nominee with Prospect: JJ JJJJJ
SECTION I:
Date of Birth: OU9UI989 Occupation: Salaried Self-employed
Relationship of Insured with Prospect:
Nominee Name: MD J JSAH /JD) JJJJJJJJJJJJ.
Relationship of Nominee with Prospect: HUJSB|No JJJIJJJJJ
Loan Status of the Prospect:. Main Applicant Co-applicant Guarantor
PAN No.: Aadhaar No.:
PAGE 1OF 4
 CUSTOMER INFORMATION- PART A(CONTD,)
LOAN DETAILS
Loan Account No. (LAN): Loan Tenure: years

One EMI Amount:

Type of Loan to be insured: HOME LOAN LAP Others
Loan Sanction Date: Loan Sanction Amount :
Loan Disbursal Date: Disbursal Amount :

Premium Details (Inclusive of GST)

Premium Amount: J J J J J DD/ Chegue Amount:
DD/ Cheque No.: JJJJ_JJJ Funded Non Funded Bank NameJJJ
DD/ Cheque Date: NEFT TransactionI D : J
"Registered GST: Yes No (One Policy One Invoice)

HYes, then pleaseprovide GSTIN:JJJJJJJ_JJJJJJJJ_

Address (Registered under GST):
JJJJJJJJJJJJJJJJJ_JJ
INCOME PROTECT-PART B
Policy Term: years Type: New Renewal In case of renewal please mention policy number

Coverage Benefit Amount Sum Insured

Section B Benefit 2: Critical lIness (CI) - 33 Cls* Loan Amount
Section BBenefit 3: Major surgical procedures (MSP) Loan Amount
Section CBenefit 4: Accidental Death Benefit (PA) Loan Amount
Section CBenefit 5: Permanent Total Disablement (PTD), Loen Amount
"Please refer to Policy wordings for other policy terms and conditions.
Date: Place: JJJJJJJJJJ Applicant Signature: Mumtaz Bequn
HEALTHSTATUS (Applicable to Both Income Protect &Group Safeguard nsurance)
01. Please confirmifyou are suffering from Diabetes,Hypertension ,High Cholestro!
Ifyes, Please specify the duration of illness
02. Has Prospect consulted with any doctor or other health care provider for any other condition or symptomis\undergone any
hospitalization for any illness or surgery. Yes No
Ifyes, Please specify details along with the duration
03. Is Prospect currently taking medication(s)/ or taken in the past for any condition or medical procedures (including diagnostc
testing). Yes No
f yes, Please specify detaits alongwith the duration
04. Any other medical condition/disability/Physical deformity arising out of any illness or Prior History of Accident: Yes No
yes, Please specitydetails
05. Does the prospect have any other Secure Mind/ Group Secure Mind/ Critical llness/ Health/ Income Protect Pohcy with ICICI
Lombard GiC Ltd.or similar policies with any other insurance company? Yes No
If yes, please provide the policy number and sum insured
06. Has ary of your previous heaBth proposal been declined by ICICI Lombard GIC Ltd. /any other insurance company in the past. if yes,
Please specity details.
PAST CLAIMEXPERIENCE
Please mertion if you have lodged any clain in the past under Secure Mind/ Group Secure Mind/ ncorme Protect/ CI/Health policy with
ICICI Lombard GIC Ltd./Under similar policies with other insurance companies in the past. If yes, please specity details

Date:JJJJJJJPlace: Applicant Signature:Muntas Bgum

PAGE 2 OF 4
DECLARATION APPLICABLE FOR ALL SECTIONS
1. Ihereby declare, on my behalf and on bchal of all persons proposer for the solo purpose of underwriting the proposal
proposed to be insured, that theabove statements, answers and/or claims settlement and with any Governmental and/or
and or particulars given by me are true and complete in all Hequlatory authority.
respects to the best of n1y knowBedge and that Iam authorised 8. Ideclare that the contents of this products covered in this forn
to propose on behalf of these other persons. and the form have been fully explained to rne and I have fully
2. Iunderstand that the information provided by me will form the understoodthesignificance of the proposed contract
basis of the insurance policy, is subject to the Board approved 9. lunderstand that the insurance coverage will cormmence not
underwriting policy of the insurer and that the policy will come earlier than the date of disbursal of loan as referred overleaf or
into force only after ful payment of the premium chargeabBe. after the futt premiurm is receivgd by ICICI Lonbard Generat
3. I further declare that I will notify in writing any change Insurance Go. Ltd whichever is later subject to underwriting
OccurTing in the occupation or general health of the life to be approval by ICICI Lombard General Insurance Compary Ltd.
insured proposerafter the enroliment form has been 10. Ibeen
also confirm and declare that the persons whose details have
mentioned in this enrollnent forn for coverage are the
submitted but before communication of the risk acceptance
by the company. Applicant(s)/ Co-applicant(s)/Guarantor of the loan.
4, Ideclare that ! consent to the company seeking medical 11. lhereby confirm that lam aware that enrolment to this oroduct
information from any doctor or hospital who/which at any time ispurely voluntary and is not linked to me availingof any other
has attended on the person to be insured/proposer or from any facility from the bank.
past or present employer concerning anything which affects 12. the
Ihereby confirm that Ihave insurable interest in the policy and
premium is not borne by any third party entity or person.
the physical or mental health of the person to be
insured/proposer and seeking information fronm any insurer to 13. We hereby give my/our consent issued to enroll me/us into
whom an application for insurance on the person to be insured Income Protect policy underwritten by ICICI Lombard General
/proposer has been made for the purpose of underwriting the Insurance Co. Ltd. (IRDA Reg No 115).
proposal and/or claim settlement. 14. We agree to abide by the Terms &Conditions of the policy
5. Ihave been provided with the detail terms of the policy. I have and provide my consent to share my personal details, as
read, understood and aware of the detaits terms of the policy. required, regarding my enroliment into the policy with the
6 Ihave read and understood the terms and conditions of the Insurer.
Policy and confirm to abide by the same. Ihereby agree that the 15. and
Weobtain
herebymy/our
give my/our consent to the Company to verify
identity/address proof as welt as the
insurance coverage/ risks under the policy wit commence
subject to realization of full premium. Receipt of this form by the identity /address proof of the insured through Central KYC
Company shall not be construed as acceptance of proposal. Registry or UIDAI or through any other modes for the
Company in its sole discretion reserves the right to accept or purpose of undertaking KYC,
reject any proposal without assigning any reasons thereof. 16. IWe hereby declare and confirm that the premium has been
7. lauthorize the company toshare information pertaining to my paid out of legally acquired sources of income and the
proposal including the medical records of the insured/ subsequent premiums if any, wil continue to be paid out of
legally declared and assessed source of income.
TWe hereby give my consent to enroll me for Income Protect Product. Part B Part C

Iconfirm that information furnished by me in my account and this enrollment form together constitute the enrollment documents for
Insurance policies.
Product Coverage Sum Insured (in Rs)
Income Protect 33 Critical llness
Major surgical procedures (MSP)
Accidental Death Benefit (PA)
Permanent Total DisabBement {PTD)

DECLARATION FOR ASSIGNMENT

IMr./Mrs/Ms: hereby assign the claim amount
payable in the event of my Death / Diagnosis/Undergoing Surgical Procedures as covered under the policy issued by ICiCILombard
General insurance Company Limited against the above mentionedproduct{s), to <Channel Name andl further declare that this receipt
shall be sufficient discharge to the Company.
Terns &Conditions
Fron the policy start date, the arnout payable by Company to the insured and all rights, title, benefits and interest of the insured
under this policystand assigned in favor of the "Bank /financial institution as named in theSchedule lof this policy"
Upon any arnount becoming payable under this policy. the same shallbe paid by the Company to the "Bank/Financial lnstitution as
named in Schedule Iof this policy', but not exceeding the Principal outstanding as defined under the policy. in the event of any
armount payable under this policy exceeding the Principal outstanding, the Company shallpay such amount as exceeding the
Principaloutstanding, to the insured.
The receipt of such amount in the manner aforesaid by the Bank/Fnancial lnstitution as named in the Schedule lof this pohcy, shal
completely discharge the Company from all the liatbility under the policy and this shallbe binding on the insured and the heirs,
executors, administrators, successurs ur leyalrepresentatives uf the insured, as the case may be.
PAGE 3 OF 4
 DECLARATION FOR ASSIGNMENT (CONTD.)
Date: Place: Mumtaz
Applicart Signature
Witness Nane:

Address:

Ihereby confhm to have provided Health Status (Medical Lifestyle Informat1on) to the best of my
knowtedge and have read and
understood the Declaration applicable to all Sections &for assignment. lam aware that enrollment to this
and is not linked to me availing of any other facility from the bank. product is purely voluntary

AGENT CONFIDENTIALITY REPORT (To be signed by Agent/ SP)

(Full Name) in my capacity as
the Specified Person of the Corporate Agent/Authorised Employee of the Broker/
Relationship
the contents of this proposal form, including the nature of the questions contained in this
Officer, do declare that Ihave explained all
proposal form to the
expiained that the statement(s), information and response(s) submitted by him/her in thís proposal form to questionsproposer. have also
I
any details sought herein will form the basis of the contract of insurance between the contained herein or
Company and the proposer, if this proposal is
accepted by the Company for iSSuance of a policy. Based on my interaction with the proposer and/or the
have been supplied with, Ihave no information, which suggests that any of the statement(s), information anddocuments and records that|
proposer or the life to be insured is/are incomplete or untrue. response(s) supplied by the

SP Code /License No./ Agent ID: j JJJJ Date:

JJJJJJJSP/Agent Signature:
DISCLAIMER:
Disclaimer: The proposal features different products namely: Income Protect ICIHLGP22084V042122. The proposer has the
choice of
purchasing any one or more products as per his/her need and choice and there is no compulsion whatsoever that these products are to
be taken together. For more details on risk factors, terms and conditions, please read the sales brochure of the
respective individual
products carefully before concluding a sale.
(Enrolling for Insurance Product is NOT MANDATORY)

STATUTORY WARNING
PROHIBITION OF REBATES
(Under Section 41 of Insurance Law)
(Amendment Act 2015)
1) Noperson 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 any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission
payabBe or any rebate of the premium shovwn on the policy, nor shall any person taking out or renewing or continuing a Policy accept
any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
2) Any person making default in complying with the provisions of this section shall be liable for a penalty, which may extend to ten
lakhs.

lCICISLombard
Nibhaye Vaade
ICICILombard General Insurance Company Limited
Mailing Address: lnterface Building No. 16, 601-602, 6th Floor, New Link Road, Malad (West), Mumbai -400 064.
Registered Office Address: ICICI Lombard House, 414, Veer Savarkar Mara, Near Siddhi Vinayak Temple, rabhadevi, Mumbai 400 025.
Vist us at www.icicilombard.com Mal us atcustomersupport@iclcilombard.conn Tol Froo No. 1800 2666 Chargabia Na.: +91 86 55 222 666
Insurance is the subject Tnatter of solicitation, IRDA Reg. No. 115. CIN: L6720OMH2000PLC129408.
UIN: lncome protect ICIHLGP22084V042122

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