HDFC Life Group Suraksha (Micro-Insurance Product)(UIN: 101N135V02)–

Appendix 7(b) - Member Informationn Form

A Non-Linked, Non-Participating Group Term Micro Life Insurance Product

MEMBER INFORMATION FORM

REGULATED ENTITY
[IMPORTANT NOTE: Any cancellation and alteration must be countersigned by Member.
Please do not sign blank Proposal form]
☑ HDFC Life Group Jeevan Suraksha (Micro-Insurance Product)
Plan:
HDFC Life Group Suraksha (Micro-Innsurance Product)
Sum Assured (INR) : 71941.8/- Premium (INR) : 1035.96/- Cover Term( mths) : 32 months. Moratorium Period(yrs)
Premium Payment Option: Regular Single ☑ Limited Premium Payment Frequency: Single ☑ Yearly Half Yearly Quarterly Monthly
Cover Type: Single Life ☑ Joint Life
Main Benefit : ( Level) Interest Rate : % Extra Life Benefit

Particulars of Member : Mr/Mrs . Mahasuda Khatun Date of Birth/Age(yrs) : 10/10/1984

Address : Alinagar, Alinagar 735216 Gender : Female
Particulars of Joint Life Assured (if any): Mr/Mrs . __________________________________________ Date of Birth/Age(yrs) :
Gender :_________________ Relationship with Member :___________________ Loan Account No 1 :_________________ Loan Account No 2 :________________ LoanType :______________
Particulars of Legal Guardian (if Member / Joint Life Assuured is a minor) : Mr/Mrs. _______________________________________________
Date of Birth/Age(yrs) :_____________________ Gender :_____________________ Relationship with Member / Joint Life Assured _______________________
PAN No : _________________________ (submit form 60 if PAN not available)

Nominee / Appointee Details :

Name Date of Birth Gender % Share Contact No . Relationship to
Nominee 1 : Aliyar Rahaman 01-01-1974 Male 100 % 7679684972 Spouse
Nominee 2 :
Appointee :

DECLARATION OF GOOD HEALTH :

1. Are you in sound state of health ? ☑ Yes No
2. Have you ever undergone, or expect to underrgo any surgical procedure for any illness, ailment, disease or disabiility ? Yes ☑ No
3. Have you ever suffered from, or are sufferinng from any disease/ailment requiring any form of medication forr more than 7 consecutive days, or been absent from work for more
than 7 days ? Yes ☑ No
For Female Lives only :
1. Are you pregnant now ? Yes ☑ No
2. If response to Qn(1) if yes, please mention how many weeks __________ ( Please attach pregnancy questionnaire)
3. Have you ever suffered from any disease of the breast, uterus, cervix, ovaries or any other part of the reproductive system ? Yes ☑ No

II Do you engage or intend to engage in any business, sport or occupation of a hazardous nature ? Yes ☑ No
III Do you have any history of conviction under any crimminal proceedings in India or abroad ? Yes ☑ No
IV Have any proposal for insurance, or revival of policy on your life to this company or any other insurance company been postponed/declined/accepted on terms other than proposed ?
Yes ☑ No

PAYMENT AUTHORISATION (if applicable)

I do hereby declare that I have received a loan froom M/s SVATANTRA MICROFIN PRIVATE LIMITED (“Master Policyholder”). In order to secure the said loan I have taken the
above referenced policy from HDFC Life Insurance Company Limited (“HDFC Life”). In consideration of receiving the said loan I hereby authorize HDFC Life to make payment
of Outstanding Loan Balance amount to Master Policyholder by deducting from the claim proceeds payable on happening of the contingent event covered by the Group Life
Insurance Scheme/ Policy referenced above.

Date : Place : Birpara Signaturee/Thumb Impression of the Member

Declaration to be made by a 3rd person where: a) The Member has affixed his/her thumb impression; OR b) The Member has signed in vernacular; OR c) The Member has not
filled the application.

I hereby declare that I have explained the contents of this application form to the Member in _________________ language and have truthfully recorded the answers provided to me. I further
declare that the Meember has signed/affixed his/ her thumb impression in my presence.

Signature/Thumb impression of Witness * Signature of the Declarant

Name & Address :________________________________________________________________________________________________________ Date :_____________________

Occupation :______________________________________________________________________________________________________ Place :______________________

* Witness Signature, Address and Occupation is required along with signature of Member

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor : I hereby declare that the content of the form and document filled up by the Member or
Joint Life Assured is accuurate and true to my knowledge.

Signature/Thumb Impression of the Signature/Thumb Impression of the

Legal Guardian (if Member is a Minor) Legal Guardian (if Joint Life Assured is a Minor)

Note: PLEASE DO NOT SIGN BLANK FORM

 PSRF317005062007 | Comp/Jun/Int/5048

COVID-19 Questionnaire for Group policies

To be filled for :
1) All Group Health Shield applications
2) Non MFI applications - for all members with Sum Assured more than INR 10 lakhs
Thank you for applying for a policy from HDFC Life Insurance Company Limited. To enable us to assess your application, please send this questionnaire duly answered and
signed by the Life to be Assured and the Master policy Holder.

Name of Life to be Assured Mahasuda Khatun

Loan Account No. Member No.

Master policy Holder Name SVATANTRA MICROFIN PVT LTD Master policy No.

1. Have you/any of your immediate family members travelled outside India in thelast 45 days or do you plan to travel outside India during
YES / ☑ NO
the next 6 months ?
2. Have you/any of your immediate family members tested positive for COVID-19* or are awaiting results of such a test or been advised to
YES / ☑ NO
be under quarantine due to COVID-19* ?
3. Are you/any of your immediate family members, currently suffering from or in the last 2 months, have suffered from fever, persistent
YES / ☑ NO
cough, sore throat, breathing difficulties, gastro-intestinal symptoms (vomiting/diarrhea) ?
* Novel Coronavirus, SARSCoV-2/COVID-19

An incomplete questionnaire will not be considered valid.

Declaration of Life to be Assured

I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by me for an insurance policy from HDFC Life
Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate the contract.

Date :
Place : Signature of Life to be Assured

Declaration to be made by a 3rd person where: a) The Member has affixed his/her thumb impression; OR b) The Member has signed in vernacular; OR c) The Member has not
filled the application.

I hereby declare that I have explained the contents of this application form to the Member in ____________ language and have truthfully recorded the answers provided to me. I further declare that
the Member has signed/affixed his/ her thumb impression in my presence.

Name : __________________________________________________________________________

Address : ________________________________________________________________________ Date : _____________________

Occupation : ____________________________________________________________________ Place : _______________________ Signature/Thumb Impression of Witness *

* Witness Signature, Address and Occupation is required along with signature of Member

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor

I hereby declare that the content of the form and document filled up by the Member or Joint Life Assured is accurate and true to my knowledge.

Name : __________________________________________________________________________ Date : ______________________

Signature /Thumb Impression of the Legal
Place : _____________________
Guardian (if Member is a Minor)

Note: PLEASE DO NOT SIGN BLANK FORM

HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off : 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com
 HDFC Life Group Suraksha (Micro-Insurance Product)(UIN: 101N135V02)–
Appendix 7(b) - Member Informationn Form
A Non-Linked, Non-Participating Group Term Micro Life Insurance Product

MEMBER INFORMATION FORM

REGULATED ENTITY
[IMPORTANT NOTE: Any cancellation and alteration must be countersigned by Member.
Please do not sign blank Proposal form]
☑ HDFC Life Group Jeevan Suraksha (Micro-Insurance Product)
Plan:
HDFC Life Group Suraksha (Micro-Innsurance Product)
Sum Assured (INR) : 71941.8/- Premium (INR) : 1035.96/- Cover Term( mths) : 32 months. Moratorium Period(yrs)
Premium Payment Option: Regular Single ☑ Limited Premium Payment Frequency: Single ☑ Yearly Half Yearly Quarterly Monthly
Cover Type: Single Life ☑ Joint Life
Main Benefit : ( Level) Interest Rate : % Extra Life Benefit

Particulars of Member : Mr/Mrs . Aliyar Rahaman Date of Birth/Age(yrs) : 01/01/1974

Address : Alinagar, Alinagar 735216 Gender : Male
Particulars of Joint Life Assured (if any): Mr/Mrs . __________________________________________ Date of Birth/Age(yrs) :
Gender :_________________ Relationship with Member :___________________ Loan Account No 1 :_________________ Loan Account No 2 :________________ LoanType :______________
Particulars of Legal Guardian (if Member / Joint Life Assuured is a minor)Mr/Mrs. ______________________________________________
Date of Birth/Age(yrs) :_____________________ Gender :_____________________ Relationship with Member / Joint Life Assured _______________________
PAN No : ___________________________ (submit form 60 if PAN not available)

Nominee / Appointee Details :

Name Date of Birth Gender % Share Contact No . Relationship to
Nominee 1 : Mahasuda Khatun 10/10/1984 Female 100 % 7679684972 Spouse
Nominee 2 :
Appointee :

DECLARATION OF GOOD HEALTH :

1. Are you in sound state of health ? ☑ Yes No
2. Have you ever undergone, or expect to underrgo any surgical procedure for any illness, ailment, disease or disabiility ? Yes ☑ No
3. Have you ever suffered from, or are sufferinng from any disease/ailment requiring any form of medication forr more than 7 consecutive days, or been absent from work for more than 7 days
? Yes ☑ No
For Female Lives only :
1. Are you pregnant now ? Yes ☑ No
2. If response to Qn(1) if yes, please mention how many weeks __________ ( Please attach pregnancy questionnaire)
3. Have you ever suffered from any disease of the breast, uterus, cervix, ovaries or any other part of the reproductive system ? Yes ☑ No

II Do you engage or intend to engage in any business, sport or occupation of a hazardous nature ? Yes ☑ No
III Do you have any history of conviction under any crimminal proceedings in India or abroad ? Yes ☑ No
IV Have any proposal for insurance, or revival of policy on your life to this company or any other insurance company been postponed/declined/accepted on terms other than proposed ?
Yes ☑ No

PAYMENT AUTHORISATION (if applicable)

I do hereby declare that I have received a loan froom M/s SVATANTRA MICROFIN PRIVATE LIMITED (“Master Policyholder”). In order to secure the said loan I have taken the above
referenced policy from HDFC Life Insurance Company Limited (“HDFC Life”). In consideration of receiving the said loan I hereby authorize HDFC Life to make payment of
Outstanding Loan Balance amount to Master Policyholder by deducting from the claim proceeds payable on happening of the contingent event covered by the Group Life Insurance
Scheme/ Policy referenced above.

Date : Place : Birpara Signaturee/Thumb Impression of the Member

Declaration to be made by a 3rd person where: a) The Member has affixed his/her thumb impression; OR b) The Member has signed in vernacular; OR c) The Member has not filled
the application.

I hereby declare that I have explained the contents of this application form to the Member in _________________ language and have truthfully recorded the answers provided to me. I further declare that
the Meember has signed/affixed his/ her thumb impression in my presence.

Signature/Thumb impression of Witness * Signature of the Declarant

Name & Address :________________________________________________________________________________________________________ Date :_____________________

Occupation :______________________________________________________________________________________________________ Place :______________________

* Witness Signature, Address and Occupation is required along with signature of Member

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor : I hereby declare that the content of the form and document filled up by the Member or Joint Life
Assured is accuurate and true to my knowledge.

Signature/Thumb Impression of the Signature/Thumb Impression of the

Legal Guardian (if Member is a Minor) Legal Guardian (if Joint Life Assured is a Minor)

Note: PLEASE DO NOT SIGN BLANK FORM

 PSRF317005062007 | Comp/Jun/Int/5048

COVID-19 Questionnaire for Group policies

To be filled for :
1) All Group Health Shield applications
2) Non MFI applications - for all members with Sum Assured more than INR 10 lakhs
Thank you for applying for a policy from HDFC Life Insurance Company Limited. To enable us to assess your application, please send this questionnaire duly answered and
signed by the Life to be Assured and the Master policy Holder.

Name of Life to be Assured Aliyar Rahaman

Loan Account No. Member No.

Master policy Holder Name SVATANTRA MICROFIN PVT LTD Master policy No.

1. Have you/any of your immediate family members travelled outside India in thelast 45 days or do you plan to travel outside India during
YES / ☑ NO
the next 6 months ?
2. Have you/any of your immediate family members tested positive for COVID-19* or are awaiting results of such a test or been advised to
YES / ☑ NO
be under quarantine due to COVID-19* ?
3. Are you/any of your immediate family members, currently suffering from or in the last 2 months, have suffered from fever, persistent
YES / ☑ NO
cough, sore throat, breathing difficulties, gastro-intestinal symptoms (vomiting/diarrhea) ?
* Novel Coronavirus, SARSCoV-2/COVID-19

An incomplete questionnaire will not be considered valid.

Declaration of Life to be Assured

I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by me for an insurance policy from HDFC Life
Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate the contract.

Date :
Place : Signature of Life to be Assured

Declaration to be made by a 3rd person where: a) The Member has affixed his/her thumb impression; OR b) The Member has signed in vernacular; OR c) The Member has not
filled the application.

I hereby declare that I have explained the contents of this application form to the Member in ____________ language and have truthfully recorded the answers provided to me. I further declare that
the Member has signed/affixed his/ her thumb impression in my presence.

Name : __________________________________________________________________________

Address : ________________________________________________________________________ Date : _____________________

Occupation : ____________________________________________________________________ Place : _______________________ Signature/Thumb Impression of Witness *

* Witness Signature, Address and Occupation is required along with signature of Member

Declaration made by Legal Guardian if any of the Member or Joint Life Assured is a minor

I hereby declare that the content of the form and document filled up by the Member or Joint Life Assured is accurate and true to my knowledge.

Name : __________________________________________________________________________ Date : ______________________

Signature /Thumb Impression of the Legal
Place : _____________________
Guardian (if Member is a Minor)

Note: PLEASE DO NOT SIGN BLANK FORM

HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off : 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com