ENROLLMENT FORM

HEALTH SHIELD 360

ICICI Bank account no:
Applicant no of New Account:
Sourcing employee's emp ID:

I authorize ICICI Bank Ltd. to debit mu Operative account number for Premium
towards Health Shield 360 Policy as per the applicable premium and remit to ICICI Lombard.

I hereby consent to avail the Health Shield 360 policy (UIN ICIHLGP22083V022122) underwritten by ICICI Lombard General Insurance Company
Limited ("ICICI Lombard"). I confirm that the information furnished by me in my operative account and this enrollment form together shall
constitute the proposal documents for the Health Shield 360 policy.
ICICI Bank has taken Health Shield 360 policy (UIN ICIHLGP22083V022122) underwritten by ICICI Lombard GIC Ltd.
ICICI Bank Ltd. is the Master Policy Holder of the policy with Master Policy No. 4177i/MSTR/267469260/00/000 and enrolling customers.

GUIDELINES FOR COMPLETION OF THE FORM (TO BE FILLED BY THE PROPOSER)

Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not to suppress any material facts in response
to the questions in the enrolment form. Please disclose all material facts while filing in the enrolment form.
The Policy shall become void at the option of Insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in
any material particular in the enrolment form/personal statement, declaration and connected documents or any material information having been withheld by the
Applicant or any one acting on his behalf.
Terms and Conditions
Initial waiting period of 30 days for all illnesses (except Hospitalisation due to injury or accident).
The liability of the insurer does not commence until this enrollment form has been accepted by the insurer and premium realized.
Declared & accepted Pre-existing diseases will be covered after initial waiting period.
Specified disease/procedure will be covered after initial waiting period.
Expense related to hypertension, diabetes and cardiac conditions will not be covered within 90 days from the policy commencement date unless they are
PED.
Premium at the time of renewal is subject to change in case of addition or deletion of the insured member and/ or basis change in age band of eldest
insured member.
The Insured person may have to undergo pre policy medical checkup at our designated network provider/ service provider depending upon his/her age and
SI opted. The insurer will bear 100% of the expenses incurred on the acceptance of the proposal. In case the proposal is not accepted, the premium shall be
refunded post deduction of the expenses incurred for the medical tests.
Pre-acceptance Tele screening is mandatory above age of 55 years and also in case customer has declare any Pre-existing disease.

APPLICANT / CUSTOMER INFORMATION Please fill all the particulars in CAPITAL letters only

Applicant Name (please leave a space after each part of name)

Mr. / Ms. / G A U R A V J A I N
Dr.:
DOB: 1 8 0 9 1 9 8 3 Gender: Male Female Transgender Mobile No. 9 8 7 3 9 7 3 6 5 8
E-mail G A U R A V . J A I N 1 @ H O T M A I L . C O M
Address:
PAN Number: Virtual ID:

Address: F L A T 6 0 2 , R E G E N T B , G R A N D O M A X E , S E C T O R
9 3 B , N O I D A

Are you or any of the proposed applicants a PEP* or a close relative of a

PEP? Yes No
If yes, please give details:_________________________________________________________________________
*Policy Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States/Governments, senior
politicians, senior govenrment/judicial/military officers, senior executives of state-owned corporations, important political party officials, etc.

NOMINEE/ APPOINTEE DETAILS

Name of S O N A L T R I P A T H I Date of 2 6 0 9 1 9 8 8
Nominee: Birth:

Relationship: S P O U S E Name of Appointee: (only applicable In case of

Minor)
DETAILS OF PERSONS TO BE INSURED
 Insured Full Name (First, Middle, Last) Gender Date of Birth Relationship Height Weight Sum
No. (M/F/T) (DD/MM/YY) with Applicant (feet / inch) (kgs) Insured

1. GAURAV JAIN M 1 8 / 0 9 / 1 9 8 3 SELF 5000000

2. SONAL TRIPATHI F 2 6 / 0 9 / 1 9 8 8 SPOUSE 5000000
3. PAIAN JAIN M 1 7 / 1 1 / 2 0 1 4 SON 5000000
4. D D / M M / Y Y Y Y Y

Are all insured Indian nationals and Indian residents? Yes No If Not, please provide details:

MEDICAL AND LIFESTYLE INFORMATION

Has the person proposed to be insured ever suffered from / is suffering from any of the following. Kindly check (✔ ) the relevant box wherever applicable as per
Insured and Pre-existing condition.

Insured 1 Insured 2 Insured 3 Insured 4

1 Hypertension High Blood pressure History

2 Diabetes Mellitus Sugar History
3 Hyperlipidemia Cholesterol History
4 Does any person proposed to be insured smoke or consume Tobacco in any form or alcohol
5 Heart and Circulatory Conditions or Disorders chest pain angina palpitations congestive heart
failure coronary artery disease heart attack bypass surgery or angioplasty valve disorder or
replacement pacemaker insertion rheumatic fever congenital heart condition varicose veins
clots in veins or arteries blood disorders anti coagulant therapy etc
6 Urinary Conditions or Disorders Blood in urine increase in urinary frequency painful or difficult
urination Kidney and or Bladder infections stones of urinary system kidney failure dialysis or
Any Other Kidney or Urinary Tract Or Prostate Disease
7 Musculoskeletal Conditions or Disorders Joint or back pain Arthritis Spondylosis Spondylitis
SPinal disorders Surgeries Osteoporosis Osteomyelitis Joint Replacement Or Any Other
Disorder of Muscle or Bone or Joint or ligaments tendons or discs gout herniated disc
fractures or accidents or implants amputation or prosthesis Muscle weakness Polio etc
8 Respiratory Conditions or Disorders Shortness or difficulty of breath Tuberculosis Asthma
Bronchitis Chronic Obstructive Pulmonary Disease COPD chronic cough coughing of blood
etc or any Other Lung or Respiratory Disease
9 Digestive Conditions or Disorders Jaundice chronic diarrhea intestinal bleeding or problems
or polyps diseases of the pancreas liver or gall bladder hepatitis A or B or C or other jaundice
Ulcerative colitis Chrons disease Inflammatory or irritable bowel disease Cirrhosis unexplained
weight loss or gain eating disorder or any Other Gastro Intestinal condition
10 Cancer or Tumor Benign Or Malignant tumor Any Growth or Cyst any Cancer diagnosed
earlier and or treatment taken for cancer
11 Brain or Nervous System or Mental or Psychiatric Conditions or Developmental Disorders or
Congenital or Birth defect Loss of consciousness fainting dizziness numbness or tingling
weakness paralysis head injury stroke migraine headaches or chronic severe headaches
sleep apnea multiple sclerosis seizures or epilepsy or any Other Brain or Nervous System
Disease Mental or Psychiatric disorder ADHD autism disability or deformity whether physical
or mental etc
12 Female Reproductive Conditionsor Disorders Pelvic pain abnormal menstrual bleeding
abnormal PAP smear endometriosis Fibroid Cyst or Fibroadenoma Bleeding Disorder Pelvic
infection Or Any Other Gynecological or Breast cysts or lumps or tumor
13 Eye Ear Nose and Throat Disorders Cataract glaucoma Opticneuritis retinal detachment
conjunctivitis squint ptosis Blindness refractive error or spectacle number in dioptres otitis
media Deviated Nasal Septum Otosclerosis Loss of speech Hearing loss nasal polyps chronic
sinusitis Any other disorder of Ear Nose and Throat
14 Sexually Transmitted Diseases HIV or AIDS immunodeficiency or any venereal disease VD or
sexually transmitted disease STD
15 Metabolic Endocrine Conditions or Disorders and autoimmune or genetic disorder Adrenal or
pituitary disorders thyroid disorder lupus scleroderma thyroid disorders Thallasemia anemia
Hemophillia Obesity and related surgeries etc
16 Is any female member pregnant tested positive with a home pregnancy test or ectopic
pregnancy infertility treatment

17 Does the person proposed to be insured suffer from any chronic or long term medical
condition or have any other disability abnormality or recurrent illness or injury or unable to
perform normal activities
18 Has any member consulted with or received treatment from any doctor or other health care
provider for any other condition or symptoms or undergone any hospitalization or illness or
surgery or currently taking medications for any condition or medical procedures including
diagnostic testing
19 Does the individual have a family history of any disease like Heart disease or brain disease or
cancer or organ failure or autoimmune or genetic disorder
 STATUTORY WARNING
PROHIBITION OF REBATES
(Under Section 41 of Insurance Act 1938)
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 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 lakh rupees.

DECLARATION
I hereby give my consent to the company to contact me for health and related services.
I 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 am authorized to propose on behalf of these other persons.
I understand that the information provided by me will form the basis of the 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 further declare that I will notify in writing any change occurring in my occupation or general health after the proposal has been submitted but before communication
of the risk acceptance by the insurer.
I declare and consent to the insurer seeking medical information from any doctor or from a hospital who has attended to my health or from any past or present
employer concerning anything which affects my physical or mental health and seeking information from any insurance company to which an application for
insurance has been made by me for the purpose of underwriting the proposal and/ or claim settlement.
I authorise the insurer 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 Government and /or Regulatory authority.
I hereby give my consent to enroll me into Health Shield 360 Insurance Policy underwritten by ICICI Lombard General Insurance Co. Ltd. (IRDA Reg No 115)
I agree to abide by the Terms & Conditions of the policy and provide my consent to share my personal details, as required, regarding my enrollment into the policy
with the insurer.

Signature of the Applicant/ Customer: Place: D D / M M /

____________________________ _________________________ DOB:
Y Y Y Y

Registered Address: ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com • Mail us at [email protected]
Toll Free Number 1800 2666 • SMS Facility "HEALTHCLAIM" to 575758 • IRDA Reg. No. 115. CIN: L67200MH2000PLC129408. UIN: ICIHLGP22083V022122