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Member Consent Form

Plan ICICI Pru Group Loan Secure Life Option

Sum Assured (INR) Premium Payment Annual One Time Pay Other Policy Term (yrs)
Total Premium Amount (in INR incl GST)1 _______________________
1The total premium amount will be inclusive of premium of all chosen benefits including death benefit. Cover Type: Reducing Immediately

Particulars of Life Assured Mr./Mrs. :

Address: Pincode:

Date of Birth/ Age: D d m m y y y y Nationality Gender: M F

Occupation Salaried Professional Selfe-employed
:
Student Housewife Retired Others (Please specify if Others)
:
Mobile No2: Email ID2:
2
Receive Communications through phone/mail
Loan Account No.
Loan Type  Unsecured Business Loan

Details Name Date of Birth Gender Contact No. Relationship to Life Assured
Nominee dd / mm / yyyy
Appointee3 dd / mm / yyyy

3
If Nominee is less than 18 years of age, Appointee is mandatory. Appointee should be more than 18 years of age

Personal Details of the Life to be Assured – Detailed Medical Questionnaire

SUPPRESING FACTS OR GIVING WRONG INFORMATION WILL ADVERSELY IMPACT PAYMENT OF YOUR CLAIM
1. Age Proof Passport Driving License School/College Certificate Others (Please specify if Others)

a. Height (ft/inches) : b. Weight (kgs)

Please answer the below mentioned medical questions (Q.No.2 to 10)
2. Do you consume or have consumed any of the following? Yes No
i. Do you smoke more than 10 cigarettes/beedis a day? ii. Do you consume more than 60ml of alcohol in a day? iii. Do you consume any narcotics?
iv. Do you chew more than 30 gms of Tobacco (Gutka) per day?
3. Lifestyle Details of life to be assured: Yes No
i. Is your occupation associated with any specific hazard or do you take part in activities or have hobbies that could be dangerous in any way? (e.g.
occupation – chemical factory, mines, explosives, radiation, corrosive chemicals & hobbies – aviation other than as a fare paying passenger, diving,
mountaineering, any form
of racing, etc.)
4. Family details of the life to be assured (include parents/sibling) Are any of your family members suffering from/have suffered from/have died of heart
disease, Diabetes Mellitus, cancer, or any other hereditary/familial disorder, before 55 years of age? If yes, please provide details here________ Yes No
5. Have you lost weight of 10 kgs or more in the last six months? Yes No
6. Do you have any congenital defect/abnormality/physical deformity/handicap? Yes No
7. Have you undergone or been advised to undergo any tests/investigations or any surgery or hospitalized for observation or treatment in past? Yes No
8. Did you have any ailment/injury/accident requiring treatment/medication for more than a week or have you availed leave for more than 5 days on
medical grounds in the last two years? Yes No
9. Have you ever suffered or been diagnosed with or been treated for any of the following? Yes No
Hypertension/High BP/high cholesterol Chest pain/Heart attack/any other heart disease or problem
Undergone angioplasty, bypass surgery, heart surgery Diabetes/High blood sugar/sugar in urine
Asthma, Tuberculosis or any other respiratory disorder Nervous disorders/stroke/paralysis/epilepsy
Any Gastro intestinal disorders like Pancreatitis, colitis etc. Liver disorders/Jaundice/Hepatitis B or C
Genitourinary disorders related to kidney, prostate, urinary system Cancer, Tumour, Growth or cyst of any kind
HIV infection/AIDS or positive test for HIV Any blood disorders like anaemia, Thalassemia etc
Psychiatric or mental disorders Any other disorder not mentioned above, please mention here_________________
10. To be answered by FEMALE lives only Yes No
a. Have you ever suffered/are suffering from or have undergone any investigation or treatment for any gynecological complications such as, disorder of
cervix, uterus, ovaries, breast, breast lump/cyst etc.?
b. Are you pregnant at present? If yes, please mention number of weeks _________________
Covid 19 – Questions
1. In the last 3 months have you been tested positive for COVID-19? Yes No
2. In the last 3 months have you been self-isolated with symptoms on medical advice? Yes No
3. In the last 1 month have you been advised to self-isolate due to COVID-19 (excluding mandatory government orders to remain at home)? Yes No
4. In the last 1 month have you had a persistent cough, fever, raised temperature or been in contact with an individual suspected or confirmed
COMP/DOC/Dec/2021/3012/7155

to have COVID-19? Yes No

Split Payment Authorization
I do hereby declare that I have received a loan from Clix Capital Services Pvt Ltd (“Master Policyholder”). In order to secure the said loan I have taken the above
referenced policy from ICICI Prudential Life Insurance Company Limited. In consideration of receiving the said loan I hereby authorize ICICI Prudential Life Insurance
Company Limited 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. In this regard, the remaining proceeds of the claims due may accordingly
be addressed in the name of the nominee. The above declaration and other details as furnished by me, are true to the best of my knowledge.

___________________________________________________
Date and Place : ______________________ Signature/Thumb Impression of the Insured Member
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Payout Mode (Choose any one mode only)

Mode selected would be used by the company to make payout(s). Payout would be in accordance and subject to the terms and conditions of the policy. Cheque
would be used if none of the below Electronic Payout Option is chosen.

1. Mode of deposit ECS Direct Credit (Select Banks only) NEFT 2. Account Type Current Savings

3. Bank Name 4. Bank Branch

5. Account Number 6. MICR Code

7. IFSC Code

Note: 1. please provide a cancelled copy of your cheque if any of the above payout option is selected. 2. In case of non credit to my bank account with/ without
assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete/ incorrect information, I would not hold ICICI Prudential
Life Insurance Co. Ltd. responsible. 3. Further, the Company reserves the right to use any alternative payout option in spite of opting for Direct Credit option.

________________________________________
Signature of Proposer

Declaration and Authorization

I/We declare that I/we have signed the form after understanding its contents and have furnished true and complete information without withholding any material
information. I/We shall immediately notify any change in information, subsequent to signing this form and before the receipt of the Certificate of Insurance. I/We
understand that the terms and conditions including the benefits are in accordance to applicable laws as amended from time to time. I/We authorize the Company to
assess and verify the health status of the life/lives to be assured through medical examinations including HIV1/2 test. The Company reserves the right to accept,
decline or offer alternate terms on my/our proposal for Life/Health Insurance. I/we authorize the past and present employer(s)/business associates/medical
practitioner(s)/hospital and medical source/any insurer to provide records to the Company for assessing risk under this proposal and any time thereafter. I/We have
understood the terms and conditions of the Group insurance schemes Rules of Clix Capital Services Pvt Ltd offering ICICI Pru Group Loan Secure product and I wish
to be a member of the scheme. I, authorize the Group organizer Clix Capital Services Pvt Ltd to take group insurance on my behalf. I/We certify that the content of
the proposal form have been clearly explained to me/us and I/We have fully understood them. I/We further certify that the replies in the proposal form have been
recorded as per the information provided by me/us. In case of fraud or misstatement by me/us, the policy shall be treated in accordance with Section 45 of the
Insurance Laws (Amendment) Act, 2015 as amended from time to time. I/We authorize the Company to mail service communications to my email id as provided.
I/We agree and authorize the Company to verify/share my/our documents/ other information provided herein on confidential basis within ICICI group and/or with
third party agencies or if sought by any public authority. I hereby authorize ICICI Prudential Life Insurance Company Limited that in case of difference between the
premium received from the applicant and the actual premium required for sought benefits, the sum assured amount /tenure may get adjusted and the policy shall
be issued accordingly.

Date: Place: ______________________________________________________________

Signature/Thumb impression of Proposer / Life to be Assured
Declaration & Authorization
Declaration to be made by a 3rd person where: a) The insured member has affixed his/her thumb impression; OR b) The insured member has signed in
vernacular; OR c) The insured member has not filled the application.
I hereby declare that I have explained the contents of this application form to the insured member in ____________language and have truthfully recorded the answers
provided to me. I further declare that the insured member has signed/affixed his/ her thumb impression in my presence.

Name & Address :

Date & Place: ____________________________________________________ Occupation : _________________________

_________________________________
Signature of Witness4
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Witness Signature, Address and Occupation is along with signature of Insured Member

COMP/DOC/Dec/2021/3012/7155