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

GUIDELINES FORCOMPLETIONOF THE FORM (To be fillad by the proposer)

Insurance is a contract of Utmost Good Faith requiring the Proposer not only to disclose allmaterial facts, but also
not tosuppress any material facts.
*A material fact will mean 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 Insurer, 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 proposal has been accepted and premium is duly
received by the company.
/We 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 shall be considered for acceptance
for a reduced sum insured appropriate to the premium realised by the insurer and the policy shall finalised and
issued accordingly.
Said Se KA
Date:
J J J J JPlace:JJJ_ J J J Applicant Signature:
CUSTOMER INFORMATION - PART A
The application form is to be filled in CAPITALLETTERS by the Proposer. Please answer all questions fully and correctly. Where any
question oes not apply. please mention clearly the question is not applicable.
PROPOSER DETAILs
Name of the Proposer:SIAJHULSEJK]H J_
Gender: Male Female Third gender
Mailing Address of Proposer: JJJJJJJJJ_JJJJ
JJJJJJJJJJJJ_JJJJJ Pincode: J J J
Mobile No.:JJJJJJJJJJ Email ID:
PAN No.: J J J J J J JAadhaar No.:JJJJJ_JJJJJJJ
Are you or any of the proposed applicants aPEP* or aclose relative of aPEP*? Yesj NoJIfyes, please give details:
*PoliticalvExposedPersons (PEPs) are individuals who are or have been entrusted with prominent public functions in aforeign country, e.g., Heads of States/
Governments, seniorpoliticians,senior government/judicial/military officers, seniorexecutives of state-ownedcorporations, importantpoliticalparty officials, etc.
PROSPECT DETAILS
SECTION I: (f Insured and prospect are samethen skip SECTION Iand move to SECTION H)
Name of the Prospect: M1/ Mrs/ Ms/ Dr. JJJJJ_JJJJJJJJJJJ
Gender: Male Female Third gender
Mobile No.: JJJJJJJJJJEmail lD:
Nominee Name:

Relationship of Nominee with Prospect:JJJJJJJUJJJJJJJJJJ_JJJ

SECTIONW:
Date of Birth: o o U 9 7 S Occupation: Salaried Self-employed
Relationshipof Insured with Prospect:
Nominee Name: G ojAPJ_JNAJBUJSEKH_JJJJJ
Relationship of Nominee with Prospèct: EATHeJJJJJJJJ_JJJJJJJJJ
Loan StatHs of the Prospect: Main Applicant Co-applicant Guarantor
PAN No.: j Aadhaar No.:
PAGE 1 OF 4
 CUSTOMER INFORMATION- PART A(CONTD,)
LOAN DETAILS
Loan Account No. (LAN): 1 I I | T ILoan Tenure: Vears
One EMI Amount:
Type of Loan to be insured: HOME LOAN LAP Others
Loan Sanction Date:
JJJJJJJoan Sanction Amount : J J JJJ JJJJ JJJ
Loan Disbursal Date: |Disbursal Amount :
Premium Details (Inclusive of GST)
Premium Amount :
JJJJDD/ Cheque Amount:JJJJJJJ_
DD/ Cheque N o . : J Funded Non Funded Bank Name JJJJJJJJ.
DD/ Cheque Date: NEFT Transaction ID:
*Registered GST: Yes No (One Policy One Invoice)
rYes, then please provide
Address (Registered under GST): GSTIN:JJ_JJJJJJJJ_JJJJJJJJ
JJJJJJJJJJJJJJJJJJJJJJW
INCOME PROTECT- PART B
Policy Term: J _ 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 CIs* Loan Amount
Section B Benefit 3: Major surgical prOcedures (MSP) Loan Amount
Section CBenefit 4: Accidental Death Benefit (PA) Loan Amount
Section CBenefit 5:Permanent Total Disablement (PTD) Loan Amount
*Please reter to Policy wordings for other policy terms and conditions.
Date: J Place:JJ Applicant Signature: Sah Serh
HEALTH STATUS (Applicable to Both Income Protect &Group Safeguard Insurance)
01. Please confirm if you are suffering from Diabetes Hypertension ,High Cholestro!
If yes, Please specify the duration of illness
02. Has Prospect consuted with any doctor or other health care provider for any other condition or symptom<sundergone any
hospitalization for any illness or surgery. Yes No
If yes, 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 diagnostic
testing). Yes No
f yes, PBease specify detaits along with the duration
04. Any other medical condition/disability/Physical deformity arising out of any ilness or Prior History of Accident: Yes No
fyes, Please specify details
05. Does the prospect have any other Secure Mind/ Group Secure Mind/ Critical llness/ Health/ Income Protect Policy with ICIC!
Lombard GIC Ltd. or similar policies with any other insurance company? Yes No
Ifyes, please provide the policy number and sum insured
06. Has any of your previous health proposal been declined by ICICI Lombard GIC Ltd. /any other insurance company in the past. If yes.
Please specify details:
PAST CLAIM EXPERIENCE

Please mention if you have lodged any claim in the past uhder Secure Mind/Group Sécure Mind/ Income Protect/ Ci/ Health policy with
ICICI Lombard GIC Ltd. /Under similar policies with other insurance companies in the past lf yes, plsase specify details:
Salid Se ka
Date:JJJJJJJ Place:JJJJIJJJJJ jAplicant Signature:
PAGE 2 OF 4
 DECLARATION APPLICABLE FOR ALL SECTIONS
1. Ihereby decare,'on my behalf and on behalf of all persons proposer for the sole purpose of underwriting the proposal
proposed to be insured, that the above statements, answers and/or claims settlement and with any Governmental and/or
and/or particulars given by me are true and complete in all Regulatory authority.
respects to the best of my knowiedge and that lam authorised 8. Tdeclare that the contents of this products covered in this form
to propose on behalf of these other persons. rme and Ihave fuly
and the form have been fully explained to
understood the significance of the propUsed contract
2. Iunderstand that the information provided by me willform the coverage will Commence not
basis of the insurance policy, is subject to the Board approved 9. lunderstand that the insurance
disbursal of loan as referred overleaf or
underwniting policy of the insurer and that the policy willcome earlier than the date of
into force only after fult payment of the premium chargeabBe. after the futl premium is received by ICICI Lombard General
3. Ifurther declare that I will notify in writing any change Insurance Co. Ltd whichever is later subject to underwriting
occurring in the occupation or general health of the life to beapproval by ICICI Lombard General lnsurance Company Ltd.
Insured/proposer after the enrollment form has been 10, also confirm and declare that the persons whose details have
submitted but before communication of the risk acceptance been mentioned in this enrollment form for coverage are the
by the company. Applicant(s)/ Co-applicant(s)/Guarantor of the loan.
4. declare that consent to the company seeking medical 11. lhereby confirm that lam aware that enrolment to this product
information from any doctor or hospital who/which at any time is purely voluntary and is not linked to me availing of any other
has attended on the person to be insured/proposer or from any facility from the bank.
past or present employer concerning anythingwhich affects 12. Ihereby confirm that Ihave insurable interest in the policy and
the physical or mental health of the person to be the premium is not borne by any third party entity or person.
insured/proposer and seeking information from any insurer to 13. We hereby give my/our consent issued to enrol 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. Ihave and provide my consent to share my personal details, as
read, tnderstood and aware of the detais terms of the policy. required, regarding my enroiment 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. We herebygive my/our consent the Company to verify
and obtain my/ouT identityfaddress proof as well as the
insurance coverage/ risks under the poficy wil! commence
subject to realization of fullpremium. 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 anyproposal without assigning any reasons thereof. 16. We hereby declare and confirm that the premium has been
7. lauthorize the company to share 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, willcontinue to be paid out of
legally declared and assessed source of income.
I We hereby give my consent to enroll me for Income Protect Product. Part B Part C

lconfirrnthat 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 lIness
Major surgical procedures (MSP)
Accidental Death Benefit (PA)
Permanent Fotal DisabBerment (PTD)

DECLARATION FOR ASSIGNMENT

IMr./MrsJMs: - hereby assign the claim amount
payable in the event of my Death/ Diagnos0s / Undergoing Surgical Procedures as covered underthe policy issued by |CiCI Lombard
General nsurance CompanyLimited against the above mentioned product(s), to <Channel Name> andlfurther declare that this receipt
shall be sufficient discharge to the Company.
Terms &Conditions
From the policy start date, the amount payable by Cornpar1y to the insured and atlights, title, benefits and interest of the insured
under this policy stand assigned infavor of the "Bank/financial institution as named inthe Schedule lof this policy"
Upon any amount becoming payable under this policy, the same shallbe paid by the Company to the "Bank/Financial lnstitution as
named inSchedule Iof this policy", but not exceeding the Principal outstanding as defined under the policy. In the event of any
amount payable under this policy exceeding the Principal outstanding, the Company shallpay such amount as exceeding the
Principal outstanding, to the insured.
The receipt of such amount in the manner aforesaid tby the Bank/Financial Institution as named in the Schedule lof this poicy, shai
completely discharge the Company from all the liability under the policy and this shall be binding on the insured and the heirs,
executors, administrators, successors or legal representatives of the insured, as the case may be.
PAGE 3 OF 4
 DECLARATION FOR ASSIGNMENT (CONTD.) Sowd Sehh
Applicant Signature:
Date: Place:
JJIJJJJJJJ
Witness Name:

Address:

have read and

Ihereby confm to have proided Health Status (Medicat &Lifestyle Information) to the best of my knowBedge and voluntary
aware that enrollment to this product is purely
understood the Deckaration applicable to all Sections &for assignment. I am
and is not linked to me availing of any other facility from the barnk.

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

(Fufl Name) in my capacity as
Relationship Officer, do declare that Ihave explained all
the Specified Person of the Corporate Agent/Authorised Employee of the Broker/ this proposal form to the proposer. I have also
the contents of this proposal form, including the nature of the questions contained in
proposal form to questions contained herein or
expiained that the statement(s), information and response(s) submitted by him/her in this Company
any details sought herein willform the basis of the contract of insurance between the and the proposer, if this proposal is
the documents and records that I
accepted by the Company for issuance of a policy. Based on my interaction with the proposer and/or
and response(s) supplied by the
have been suppliedwith, Ihave no information, which suggests that any of the statement(s), information
proposer or the life to be insured is/are incomplete or untrue.
SP Code / License No./ Agent ID: JJ JDate:JJJJJJjSP/Agent Signature:

DISCLAMER:
proposer has the choice of
Disclaimer: The proposal features different products namely: Income Protect ICIHLGP22084V042122. The
whatsoever that these products are to
purchasingany one or more products as per his/her need and choice and there is no compulsion
brochure of the respective individual
be taken together. For more details on risk factors, terms and conditions, please read the sales
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) No person shal allow or offer toallow, 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
payabBe or any rebate of the premium shown on the policy, nor shal any person taking out or renewing or continuinga PoBlicy accept
any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the lnsurer.
2) Any person making default in complying with the provisions of this section shallbe iable for apenalty, which may extend to ten
lakhs.

lcIcSLombard
Nibhaye Vaade
ICICI Lombard General Insuranco Company Limited
Mailing Address: Intertace Building No. 16, 601-602, 6th Floo., New Link Road, Malad (West), Mumbai -400 064.
Registored Office Address: ICICILombard House, 414, Vesr Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.iciciombard.com " Mailus at [email protected] "Tot Free No.: 1800 2666 " Chargable No.: +91 86 55 222 666
Insurance is the subject matter of solicitation, IRDA Reg. No. 115. CIN: L67200MH2000PLC129408.
UIN: Income protect ICIHLGP22084V042122

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