Membership Form cum Declaration of Good Health

IMPORTANT NOTE : Any additional text written or qualification given in the form would make it invalid.

Name of the Policyholder : Kotak Mahindra Bank Ltd. Policy Number : GO000036
Product Name : Kotak Group Secure One Product UIN No.: 107N098V02 Plan Option : Easy Secure
PARTICULARS OF THE LIFE ASSURED
Mr. / Ms. : BIKASH SINGH

Unique Identification Number : 750910160 CoverAmount opted for: 10,00,000/- Customer ID: KL124460106
NOMINEE DETAILS
Name : Sangita kaur
Relationship to Life to be Insured : Mother
*Nominee needs to be a major i.e. above 18 years of age and should be one of the following: Husband, Wife, Son, Daughter, Father, Mother, Brother, Sister, Grandfather or Grandmother. * Incase
of Nominee being a Proprietor/Partnership Firm/Limited Company the above condition would not apply.

DECLARATION OF GOOD HEALTH

I hereby declare that :

1.I am in good health.
2.I perform all my routine activities independently.
3.I have never had any physical defect, deformity or disability# affecting my day to day activities.
4.I have never suffered and am not currently suffering from:
a) High Blood Pressure, Heart Attack or any other Heart Disease;
b) Stroke, Paralysis in any form, or any other Cerebrovascular Disease;
c) Diabetes or any other Endocrinal Disease, Kidney Disease;
d) Any Chronic Liver Disease;
e) Any Lung Disease (eg. Chronic Obstructive Pulmonary Diseases, Parenchymal lung Disease, Pulmonary Embolism etc).
f) Blood Disorders, Gastro-Intestinal Diseases, or any other disorder of the bones, spine or muscle;
g) Any Cancer or Cancerous growth;
h) Any Mental or Psychiatric condition, any Genetic Disease or any disease related to central nervous system (disease related to brain);
i) HIV / AIDS or AIDS related complications.
5.I have never undergone nor have I been advised to undergo any major surgical procedure.
6.In the last 2 years, I have not -
a) been continuously hospitalised for more than 7 days (other than fractures of leg or arm).
b) undergone any investigations (including basic radiological and blood tests) other than normal Health Check-ups and Insurance Medicals, or
c) had adverse result for any blood tests, X-Rays, ECG, Stress Test, Biopsies, CT Scan, MRI, Ultrasonography or 2D / 3D Echo etc.
7.I do not engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature.
# Disability means inability to function normally, physically or mentally

I further declare that the above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Kotak Mahindra Life Insurance
Company Ltd [KLI].

I further hereby agree and give my consent to, the Policy holder for use of the contents of this declaration by KLI for examining and processing any claim arising, in respect of the insurance cover
that may be provided to me under the referred group policy.

I hereby confirm that my intent to participate in the above plan for the Policyholder's customers is purely on a voluntary basis, and have further understood the terms and conditions of life insurance
cover that maybe extended to me. I confirm and agree that the insurance cover, if provided, will be governed by the provisions of the Insurance Act 1938 and the Policy Contract under which the
cover will be offered to me.

I agree and understand that if I contract any of the above diseases between submitting this document and the date of commencement of the cover, I shall not be covered under the policy. I have
also not withheld any material information or suppressed any fact. I undertake to notify KLI ('The Company") of any change in my state of health or occupation or any decisions subsequent to the
signing of this declaration form and before the acceptance of the risk by the Company.

I understand and agree that if any untrue statement be contained herein, I, my heirs, executors, administrators or assignees shall not be entitled to receive any benefits which may be provided to me
on the faith of this declaration, including, inter alia the aforesaid insurance cover.

I understand and acknowledge that insurance cover shall be as per terms and conditions detailed in the Policy Contract issued by KLI in favour of the policyholder and that KLI's decision in respect
of all aspects of the referred group life insurance plan shall be final & binding.

I hereby agree to and authorize the Policyholder / my Doctor / Hospital / Local, State, Central authority / Dealer / Distributor /my Employer to divulge or convey any information or particulars relevant
to this Form / my admission into the referred Group Insurance Policy to KLI at any point during the continuance of my cover hereunder including any claim under the said Policy. I also permit KLI to
approach me directly for any clarification and / or other purposes.

I hereby declare, in case of fraud, misrepresentation and suppression of material facts the Certificate of Insurance shall be treated in accordance with the Sec 45 of the Insurance Act,1938 as
amended from time to time.

I declare that my annual income is more than Rs. 2 lakhs, i also declare that these statements are true 750910160-12/03/2024-06:51 PM
Date: 12-March-2024
Signature / Right Thumb impressions of life to be insured
Place : <<Digitally Authenticated by the customer using Kotak Banking Applications / Voice call from Kotak Mahindra Bank Limited >>

DECLARATION BY LIFE ASSURED / PROPOSER WHERE SCRIBE IS INVOLVED

I hereby declare that the contents of the form and documents have been fully explained to me and that I have fully understood the significance of the proposed contract

Place : NA Date : NA Signature of the Life Assured/Proposer : NA

DECLARATION WHERE SCRIBE IS INVOLVED (COMPULSORY FOR ALL DECLARATIONS SIGNED IN ANY VERNACULAR LANGUAGE)

I ___________ _______________________ (full name of scribe) have explained to the member the contents of this form in his own language and he/ she has fully
understood the same,. Also, I have explained that if any untrue statement is contained herein, the member, and/or the heirs, executors, administrators, assignees of the member shall not be entitled
to receive any benefits, including, inter alia, benefits under any insurance policy procured on the faith of this Form.

Place : NA Date : NA Signature of the Scribe : NA

Place : NA Date : NA Witness / Policyholder Authorized Signatory : NA

Section 41 of the Insurance Act, 1938 states: (1) 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 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.

Section 45 of the Insurance Act, 1938 States: The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above contract. Please refer to Section 45 either on our
website or contact our intermediary or visit the nearest branch for the full text.

Free Look Period : The member is offered 15 days free look period from the date of receipt of the Certificate of Insurance wherein the Member may choose to return the Certificate of Insurance
within 15 days of receipt if s/he is not agreeable with any of the terms and conditions of the plan and receive the applicable refund amount.

Kotak Mahindra Life Insurance Company Ltd. CIN : U66030MH2000PLC128503, Regn. No.: 107, Regd. Office: 2nd Floor, Plot # C- 12, G- Block,
BKC, Bandra (E),Mumbai- 400 051. Website: http://insurance.kotak.com Email:[email protected]. Toll Free No. - 1800 209 8800

Ref : No.KLI/20-21/Sec-xx

Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.
 COVID-19 (Coronavirus) Exposure Declaration
IMPORTANT NOTE : Any additional text written or qualification given in the form would make it invalid.
Name of the Policyholder : Kotak Mahindra Bank Ltd. Policy Number : GO000036

Declaration for COVID-19 (Coronavirus) Exposure

I hereby declare that :

1. I have never been in close contact with anyone who has been quarantined or who has been diagnosedwith novel coronavirus (SARS-CoV-2/COVID-19) .
2.I have never been quarantined due to a possible exposure to novel coronavirus (SARS-CoV-2/COVID-19).
3.I have neither been advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus (SARS-CoV-2/COVID-19) nor, I am awaiting the result of a test which has already been submitted
for the novel coronavirus (SARS-CoV-2/COVID-19).
4.I have never tested positive for the novel coronavirus (SARS-CoV-2/COVID-19.
5.I have not experienced any of the following symptoms within the last 14 days-
● Any fever,
● Cough,
● Shortness of breath,
● Malaise (flu-like tiredness),
● Sore throat,
● Rhinorrhea (mucus discharge from the nose),
● Gastro-intestinal symptoms such as nausea, vomiting and/or diarrhea.
6.Travel Declaration
a) I have not travelled out of India in past 14 days
a) I do not have any future travel plans for the next 30 day7
7.I am in good health

I declare that my annual income is more than Rs. 2 lakhs, i also declare that these statements are true 750910160-12/03/2024-06:51 PM
Date: 12-March-2024
Signature / Right Thumb impressions of life to be insured
Place : <<Digitally Authenticated by the customer using Kotak Banking Applications / Voice call from Kotak Mahindra Bank Limited >>

I authorise KLI to apply the benefits under this policy, first towards the loan outstanding, by paying the same directly to the Policyholder and the balance,if any, may be paid to myself and/or my
nominee/legal heirs, as the case may be. I certify that this authorization is being effected in consideration of aloan obtained from the Policyholder. I further certify that the loan outstanding amount as
confirmed by the Policyholder shall be considered as final andbinding. I declare that the receipt of the benefits by the Policyholder and/or my nominee/ legal heirs shall be a valid and sufficient
discharge of KLI'sliabilities with respect to the life cover provided to me.

Kotak Mahindra Life Insurance Company Ltd. CIN : U66030MH2000PLC128503, Regn. No.: 107, Regd. Office: 2nd Floor, Plot # C- 12, G- Block,
BKC, Bandra (E),Mumbai- 400 051. Website: http://insurance.kotak.com Email:[email protected]. Toll Free No. - 1800 209 8800

Ref : No.KLI/20-21/Sec-xx

Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.