HDFC ERGO General Insurance Company Limited

Member Addition Form

1. POLICY DETAILS
Policy No
Date of Addition
Product Name
2. DETAILS OF MEMBER TO BE ADDED
Name (Mr./Ms./Mrs.)
DOB: D D M M Y Y Y Y Height cms Weight kgs
Gender: Male Female Third Gender Photo
Relationship to Self Spouse Mother Father Son Daughter Father-in-law
Policyholder: Mother-in-law Grandchild Grand parent
Education: Post Graduate Graduate Diploma 12th Pass 10th Pass Below 10th Others ____________________________
Occupation Class***:
Annual Income: #
Mobile:
Aadhar Number:
Name of Organization:
Designation:
Nature of Duty:
Nationality: Indian OCI NRI Foreign National
***Occupation Class Description OC1-Persons working inside offices/shops without exposure to working in the open, manual labour or regular on-road travel.
OC2- Persons working outside office/shops involving mild manual work, supervision of manual labour or regular on-road travel. OC3- Semi or Unskilled
workers, skilled laborers, low voltage electricians, drivers, automated machine operators with moderate to heavy manual work working in workshops or in the
open. OC4- Police, occupation or nature of job involve working in mines, with explosive, oil/gas/metal/power or chemical production, professional sports, high
voltage electricity, handling of heavy machinery or hazardous materials, heat or noise or working at heights or significant manual labor. OC5- Individuals with
unearned income (rental or interest, pension, landlords). OC6- Armed forces, sea going vessels Crews, Aircraft pilots and cabin crews, Actors, Heavy vehicle
drivers, Machine operators
3. *MEDICAL & LIFESTYLE QUESTIONNAIRE

*For regulator's reference

The below health questions would be mentioned as per the product opted
Section A & B: Health Products
Section C: Personal Accident Products
Section D- For both Health Products and Personal Accident Products

Important: You must answer the following questions truthfully. Not doing so affects your coverage in case of a Claim.
Medical History:
Section A - MEDICAL & LIFESTYLE QUESTIONS FOR MEMBER TO BE ADDED
Please answer the below mentioned questions individually in Yes (Y)/No (N).
1. Has an ailment or disability or deformity including due to accident or congenital disease
2. Has planned a surgery
3. Takes medicines regularly
4. Has been advised investigation or further tests
5. Was hospitalized in the past
6. Is Pregnant
7. None of the above

ADDITIONAL MEDICAL QUESTIONS [RELEVANT SECTION TO BE DISPLAYED WHEN ANSWERED YES IN PREVIOUS QUESTION]
1. Has an ailment or disability or deformity Yes No. If Yes, please provide the below details
Please tick additional information about your ailment for
Hypertension / High blood pressure
Diabetes / High blood sugar / Sugar in urine
Cancer, Tumour, Growth or Cyst of any kind
Chest Pain / Heart Attack or any other Heart Disease / Problem
Liver or Gall Bladder ailment / Jaundice / Hepatitis B or C
Kidney ailment or Diseases of Reproductive organs
Tuberculosis / Asthma or any other Lung disorder
Ulcer (Stomach / Duodenal), or any ailment of Digestive System
Any Blood disorder (example Anaemia, Haemophilia, Thalassaemia) or any genetic disorder
HIV Infection / AIDS or Positive test for HIV
Nervous, Psychiatric or Mental or Sleep disorder
Stroke/ Paralysis / Epilepsy (Fits) or any other Nervous disorder (Brain / Spinal Cord etc.)
Abnormal Thyroid Function / Goiter or any Endocrine organ disorders
Eye or vision disorders / Ear / Nose or Throat diseases
Arthritis, Spondylitis, Fracture or any other disorder of Muscle Bone / Joint / Ligament / Cartilage
Any other disease / condition not mentioned above
Please share details for your ailment
Exact Diagnosis:__________________________________________________________________________________________________________
Diagnosis Date D D M M Y Y Y Y Consultation Date D D M M Y Y Y Y
Hospital Name:___________________________________________________________________________________________________________
Please share details of your treatment:__________________________________________________________________________________________

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company
under license.
1
2. Has planned a surgery Yes No. If Yes, please provide the below detail
Please share details of surgery <name of the person proposed to be insured>
Exact Diagnosis:_________________________________________________________________________________________________________
Diagnosis Date D D M M Y Y Y Y Consultation Date D D M M Y Y Y Y
Hospital Name:__________________________________________________________________________________________________________
Proposed Surgery:_______________________________________________________________________________________________________
Please share details of your past surgery <name of the person proposed to be insured>
3. Takes medicines regularly Yes No. If Yes, please provide the below details
Please share details for your current medication <name of the person proposed to be insured>
Exact Diagnosis:_________________________________________________________________________________________________________
Diagnosis Date D D M M Y Y Y Y Consultation Date D D M M Y Y Y Y
Medicine Name:_________________________________________________________________________________________________________
Please share details of your treatment <name of the person proposed to be insured>
4. Has been advised investigation or further tests Yes No. If Yes, please provide the below details
Please provide details about investigation suggested by your Doctor <name of the person proposed to be insured>
Date of tests D D M M Y Y Y Y Type of tests_____________________________________________________________________________
Findings of tests_________________________________________________________________________________________________________
Hospital Name:__________________________________________________________________________________________________________
Please upload the investigation tests results
5. Was hospitalized in past Yes No. If Yes, please provide the below details
Please share details for your past medical condition <name of the person proposed to be insured>
Exact Diagnosis:_________________________________________________________________________________________________________
Diagnosis Date D D M M Y Y Y Y Consultation Date D D M M Y Y Y Y
Hospital Name: _________________________________________________________________________________________________________
Please share details of your past medical condition________________________________________________________________________________
6. Is Pregnant Yes No. If Yes, please provide the below details
Please share your expected delivery date with us D D M M Y Y Y Y

Section B

Do you or any of the Insured members Additional Member

Consume alcohol / tobacco / Cigarettes / Bidis / Drugs in any form (if Yes, please answer the following) Y N

How many days in a week do you consume alcohol?

Since how many years have you been smoking?

How many Cigarettes / Bidi / Cigars do you smoke in a day?

How many packets of chewing tobacco / pan masala / gutkha do you consume in a day?

Mention name of the drug you consume

Mention quantity of the drug consumption per day in mg/ml

Section C
Has the member to be added ever suffered from / is currently suffering from any of the following:
If Yes, please fill the relevant details as mentioned below
Medical History: Please answer the below mentioned questions in MM - YY of diagnosed date

Health Conditions Additional Member

1. Any Heart disorder / Angina, Heart Valve disease, Congenital Heart conditions / Angioplasty / PTCA / By Pass Surgery / Y N
Valve replacement etc or any other Cardiac disorder?

2. Stroke, Epilepsy (fits), Paralysis or any other nervous system (Brain, Spinal cord, etc) disorder Y N

3. Any complication related to / due to Diabetes or Hypertension Y N

4. Tumor (Swelling)-benign or malignant, any external ulcer / growth / cyst / mass anywhere in the body? Y N

5. Arthritis, Spondylosis or any other disorder of the muscle / bone / joint Y N

6. Psychiatric/ Mental illnesses disorder Y N

Section D

Are you having any disability / deformity including accidental or congenital? Y N

If Yes, Kindly tick the specific boxes that are applicable:
Amputation
Musculoskeletal / Locomotor
Neurological / Cerebral Palsy
Polio
Spinal cord
Stroke / Paralysis / Epilepsy (Fits)or any other Nervous Disorder (Brain / Spinal cord etc.)
Visual / Hearing disability
HIV infection/AIDS
Nervous / Psychiatric or Mental or sleep disorder
Others
**Please specify type and details in free text box- cannot be blank if Y selected for Others.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company
under license. 2
 4. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED
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 insurance policy, is subject to the Board approved underwriting policy of the Insurer 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 the occupation or general
health of the life to be insured/ proposer after the proposal has been submitted but before communication of the risk acceptance by the company. I declare and
consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/ proposer or
from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking
information from any Insurer to whom an application for insurance on the person to be insured/ proposer has been made for the purpose of underwriting the
proposal and/or claim settlement. I authorize the company to share information pertaining to my proposal including the medical records of the Insured/
Proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/ or Regulatory Authority.

Proposer/Policy holder's Signature: _____________________________________________

Date: ______________________________

Place: _____________________________

5. PAYMENT DETAILS
Instrument Type: Cheque Debit Card Credit Card Net Banking Others_____________________________________________

Relationship of Payer
Instrument Number Name of Premium Payer Bank Details Date Amount (Rs.)
with Proposer

In case Premium is more than Rs. 100,000, please provide PAN details
Please make a A/c Payee Cheque / DD / Pay Order / Online transfers in favour of 'HDFC ERGO General Insurance Company Limited' only.

Signature of the receiver and official seal:___________________________________________

6. CHECKLIST

Please check the following documents are attached along with the proposal form

1. ID Proof: Passport / Pan Card / Voter ID / Driving License / Letter from a recognized public authority
2. Proof of residence: Telephone Bill / Bank Account Statement / Letter from any recognized public authority Electricity Bill / Ration Card
3. Age Proof: Proof of Age or proof of having Aadhaar
4. Renewal notice with claim details
5. Photocopies of all previous policies and endorsements
6. Income proof documents [To be provided only if my: health Critical Illness add-on cover and/or Personal Accident Products is opted]
• ITRs for last 2 FY
• Salary slips for last 3 months

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay
Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company
under license. 3