Apollo Munich HEALTH PLAN - Citi Bank · 8) Maternity benefit Not covered Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit

Apollo Munich Health Plan tailor made exclusively

for you to offer them coverages like never

before. The Plan is designed to answer all your health insurance

requirements and allows you to choose the plan

option suited to your requirement.

Points to Remember

1 Maximum Age: The maximum entry age is 65 years. There is no maximum cover ceasing age in this policy.

2 Minimum Age: The minimum entry age is 91 days. Children between 91 days and 5 years can be insured if either parent is getting insured under this policy.

3 The cover will be valid for 1 or 2 year(s) as opted. An additional 7.5% discount is offered on the premium if you choose a 2 year policy.

4 An individual and/or his family members namely spouse, dependent children, dependent parents or parents-in-law are eligible for buying this cover on an individual or floater basis.

5 A maximum of 6 members can be added in a single policy, whether on individual or floater basis. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law.

6 The insured and his family cannot select sum insured across variants in a single policy/application.

Apollo MunichHEALTH PLAN

Features and Benefits:

Apollo Munich Health Plan - Individual

Silver Gold Platinum

Basic Sum Insured per Insured Person per Policy Year (Rs. in Lakh)

2.00, 3.00, 4.00, 5.00 7.00, 10.0015.00, 20.00, 25.00, 50.00

1a) In-patient Treatment Covered Covered Covered

1b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days

1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days

1d) Day Care Procedures Covered Covered Covered

1e) Domiciliary Treatment Covered Covered Covered

1f) Organ Donor Covered Covered Covered

1g) Daily cash for choosing shared accommodation

Rs.500 per day maximum upto Rs.3,000



1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization

Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above

2) Restore Benefit

Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above.

Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year.


3) Multiplier Benefit Not Covered

Bonus of 50% of the Basic Sum Insured for every claim free year, maximum up to 100%. In case of claim bonus will be reduced by 50% of the basic sum insured However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy.


4) e-opinion in respect to a critical illness

Yes Yes Yes

5) Health Checkup Benefit Not Covered1% of sum insured subject to a maximum of Rs.5,000 per insured person at the end of every policy year.

For SI of 15 lacs : Upto 1% of the Sum insured subject to a maximum of Rs 7,500 per insured person at the end of every policy year.For SI of 20 lacs & above : Upto 1% of the Sum insured subject to a maximum of Rs 10,000 per insured person at the end of every policy year.

6) Outpatient Benefit Rs.5,000 per individual post waiting period of 2 years

Rs.10,000 per individual post waiting period of 2 years

Rs.25,000 per individual post waiting period of 2 years

7) Hospital Daily CashRs. 500 per day up to a maximum of 30 days on individual basis

Rs. 1,000 per day up to a maximum of 30 days on individual basis

Rs 2,000 per day upto a maximum of 90 days on individual basis

8) Maternity benefit Not covered

Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit of Rs.4,500) [Waiting Period of 3 years]

Not covered

9) New Born Baby cover Not covered Covered Not covered

Apollo Munich Health Plan – Family Floater


Basic Sum Insured per family per Policy Year (Rs. in Lakh)

2.00, 3.00, 4.00, 5.00 7.00, 10.0015.00, 20.00, 25.00, 50.00

1a) In-patient Treatment Covered Covered Covered

1b) Pre-Hospitalization Covered, up to 90 Days Covered, up to 90 Days Covered, up to 90 Days

1c) Post-Hospitalization Covered, up to 180 Days Covered, up to 180 Days Covered, up to 180 Days

1d) Day Care Procedures Covered Covered Covered

1e) Domiciliary Treatment Covered Covered Covered

1f) Organ Donor Covered Covered Covered

1g) Daily cash for choosing shared accommodation




1h) Emergency Ambulance Up to Rs.2,000 per Hospitalization Up to Rs.2,000 per Hospitalization

Up to Rs.2,000 per Hospitalization for SI up to 15 Lacs and up to Rs. 5,000 per hospitalization for SI 20 Lacs & above

Apollo Munich Health Plan – Family Floater


2) Restore Benefit

Auto reinstatement of Basic Sum Insured if your existing cover is exhausted during the policy year. Available only on sum insured of 3 lacs and above.



3) Multiplier Benefit Not Covered



4) e-opinion in respect to a critical illness

Yes Yes Yes

5) Health Checkup Benefit Not Covered

Upto 1% of sum insured per policy subject to a maximum of Rs.5,000 per insured person at the end of every policy year.

For SI of 15 lacs : Upto 1% of the Sum insured per policy subject to a maximum of Rs 7,500 per insured person at the end of every policy year.For SI of 20 lacs & above : Upto 1% of the Sum insured per policy subject to a maximum of Rs 10,000 per insured person at the end of every policy year.

6) Outpatient Benefit Rs.5,000 per family post waiting period of 2 years

Rs.10,000 per family post waiting period of 2 years

Rs.25,000 per family post waiting period of 2 years

7) Hospital Daily CashRs. 500 per day up to a maximum of 30 days on individual basis

Rs. 1000 per day up to a maximum of 30 days on individual basis

Rs 2000 per day upto a maximum of 90 days on individual basis

8) Maternity benefit Not covered

Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit of Rs.4,500) [Waiting Period of 3 years]

Not covered

9) New Born Baby cover Not covered Covered Not covered

Other Features• Lifelong renewal: Renew your cover lifelong and stay covered forever.

• No sublimit or copay: Enjoy your health plan without sub limits and copays.

• Cashless transactions: Apollo Munich Health Plan enables you to get treated on a cashless basis across 4000 hospitals in over 800 cities.

• No geography based sub-limits: No matter where you buy your policy you can get treated in any city or hospital you like in the country with no additional copays or sub limits.

• No claim based loading: We will never load your renewal premium because you claimed or fell ill after taking our policy.

• Quick turnaround time: You don’t have to worry about pre-authorization, 90% of pre-authorization is done within 2 hours.

• Quick claim payment: When it comes to claim settlement, we’re one of the fastest in the industry to honour every genuine claim.

• Easy upgrade: This health plan also comes with an easy upgrade option. You can upgrade your cover to the next slab at the time of your policy renewal.

• Tax benefits: You can avail tax benefits for the premium amount under Section 80 D of the Income Tax Act. (Tax benefits are subject to changes in tax)

Exclusions:• Any treatment within 30 days of cover except any accidental injury

• Any pre existing diseases/conditions will be covered after a waiting period of 2 years in Platinum Plan option & 3 years in Silver and Gold Plan.

• 2 year exclusion for specific diseases like cataract, hernia ,hysterectomy, joint replacement etc

• Expenses arising from HIV or AIDS and related diseases

• Abuse of intoxicant or hallucinogenic substance like drugs and alcohol.

• Hospitalization due to war or an act of war or due to nuclear, chemical or biological weapon and radiation of any kind.

• Non-allopathic treatment, congenital diseases, mental disorder, cosmetic surgery or weight control treatments.

For complete exclusions please refer to the policy document

Renewal Incentives: Multiplier Benefit: A Bonus of 50% of the basic sum insured for every claim free year will be offered accumulating up to 100%. In the event of a claim, the bonus shall be reduced by 50% of the basic sum insured at the time of renewal. However this reduction will not reduce the sum insured below the basic sum insured of the policy. This benefit is applicable to only Gold and Platinum plan.

Portability: If you are insured under another Insurer`s health insurance policy, You can transfer to Apollo Munich with all your accrued benefits and due allowances for waiting periods etc to the extent of sum of previous sum insured and accrued cumulative bonus and it shall not apply to any other additional increased sum insured.

Terms of Renewal:•We offer life-long renewal regardless of your health status or previous claims

made under your policy, unless the insured person or any one acting on behalf of an insured person has acted in an improper, dishonest or fraudulent manner or any misrepresentation under or in relation to this policy or the policy pose a moral hazard.

• Grace Period - Grace Period of 30 days for renewing the policy is provided under this policy. Any disease/condition contracted during the Grace Period will not be covered and will be treated as a Pre-existing condition.

•Maximum Age – There is no maximum cover ceasing age in this policy.

•Waiting Period - The waiting periods mentioned in the policy wording will get reduced by 1 year on every continuous renewal of the Apollo Munich Health Plan policy.

• Renewal premium are subject to change with prior approval from IRDAI. Any change in benefits or premium (other than due to change in age) will be done with the approval of the Insurance Regulatory and Development Authority of India and will be intimated at least 3 months in advance.

• In the likelihood of this policy being withdrawn in future, intimation will be sent to insured person about the same 3 months prior to expiry of the policy. Insured person will have the option to migrate to similar indemnity health insurance policy available with us at the time of renewal with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break as per portability guidelines issued by IRDAI.

• Basic Sum Insured Enhancement – Sum insured can be enhanced only at the time of renewal subject to no claim have been lodged/ paid under the policy. If the insured enhances the basic sum insured one grid up, no fresh medicals shall be required. In cases where the basic sum insured enhanced is more than one grid up, the case shall be subject to medicals. In case of enhancement in the basic sum insured waiting period will apply afresh in relation to the amount by which the basic sum insured has been enhanced. However the quantum of enhancement shall be at sole discretion of underwriting.

• Any insured person in the policy has the option to migrate to similar indemnity health insurance policy available with us at the time of renewal subject to underwriting with all the accrued continuity benefits such as multiplier benefit, waiver of waiting period etc. provided the policy has been maintained without a break.

• Child dependent after attaining the age of 25 years will be offered coverage under separate individual policy with all continuity benefits.

Discounts:• Family discount of 5% if 2 family members are covered and 10% if 3 or more

family members are covered under Apollo Munich Health Plan on Individual Sum Insured basis.

• 7.5% discount on premium if insured person is paying premium of 2 years in advance as single premium.

Free Look Period:You have a period of 15 days from policy receipt date to review your policy . If You have any objections to any of the terms and conditions, You have the option of cancelling the policy stating the reasons for cancellation and You shall be refunded the premium paid by You after adjusting the amounts spent on any medical check-up and stamp duty charges. You can cancel your policy only if You have not made any claims under the policy. All Your rights under this policy shall immediately stand extinguished on the free look cancellation of the policy. Free look provision is not applicable and available at the time of renewal of the policy.

Termination (other than Free Look Period):

• The policyholder may terminate this policy at any time by giving us written notice or call 24 x 7 CitiPhone or post internet banking login, and the policy shall terminate when such written notice or call is received. If no claim has been made under the policy, then we will refund part of the premium paid after retaining premiums as applicable short period rates in accordance with the policy document.

• We may terminate this policy on grounds of misrepresentation, fraud, non-disclosure of material facts or noncooperation by the policyholder or any insured person or anyone acting on the policyholder’s behalf or on behalf of an insured person upon 30 days notice by sending an endorsement to the policyholder’s address shown in the schedule without refund of premium.

Tax Benefit:• The premium amount paid under this policy qualifies for deduction under Section 80D of the Income Tax Act, subject to applicable tax laws.

DisclaimerThis is only a summary of the product features. The actual benefits available are as described in the policy, and will be subject to the policy terms, conditions and exclusions.

This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. with its registered office at Apollo Hospitals Complex, Jubilee Hills, Hyderabad-33. For more details on risk factors, terms & conditions, Please read the policy terms and conditions carefully before concluding sales.

All Insurance applications are subject to the Insurance Company`s underwriting and acceptance.

Section 41 of Insurance Act 1938 as amended by Insurance Laws Amendment Act, 2015 (Prohibition of Rebates):1) No person shall allow or offer to allow, 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 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 insurers.

2) Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees.

Reach Us

Customers can contact / get detailed process information for Post freelook cancellation/ termination/surrender/ and refund, Claims and Escalations / service queries

Email: [email protected]; Log on to : www.apollomunichinsurance.com

Write to Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana.

Call: 1800 3000 1401

Tariff Sheet: Apollo Munich Health Plan

Annual Individual Premium (Inclusive of goods & services tax)


Sum Insured (in INR) 2,00,000 3,00,000 4,00,000 5,00,000 7,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000

Age Group (Years) 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A

0-17 7252 8260 9349 10061 14899 16274 22312 23442 24510 28392

18-35 8080 9284 10586 11436 18488 20385 27195 28756 30230 35589

36-45 8847 10208 11681 12643 20747 22936 30499 32300 34001 40186

46-50 11267 13259 15414 16823 27877 31133 40017 42696 45228 54430

51-55 13398 15918 18641 20422 34198 38371 48657 52089 55332 67120

56-60 16401 19652 23169 25467 43227 48698 61046 65547 69799 85259

61-65 21451 25966 30850 34041 58586 66304 81893 88242 94239 116046

66-70 28250 34480 41220 45623 79060 89787 109597 118421 126757 157062

71-75 33684 41212 49353 54673 95685 108773 132603 143369 153537 190514

76-80 39744 48777 58546 64929 114803 130682 158585 171647 183985 228848

>80 45324 55712 66948 74287 133828 152461 184570 199900 214378 267029

Annual Family Floater Premiums (Inclusive of goods & services tax)



Age Group (Years) 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C 1A+1C

18-35 10880 12252 13930 15028 24252 26623 37829 39782 41626 48330

36-45 11528 13046 14865 16055 26263 28890 40816 42977 45017 52440

46-50 14066 16227 18760 20413 33639 37372 50652 53724 56624 67171

51-55 16314 19015 22147 24194 40208 44895 59611 63466 67108 80351

56-60 19345 22782 26714 29284 49298 55294 72080 77011 81671 98610

61-65 24395 29097 34397 37859 64657 72898 92926 99708 106112 129400

66-70 31194 37610 44765 49440 85131 96383 120631 129887 138628 170416

71-75 36628 44342 52899 58490 101756 115367 143636 154833 165408 203867

76-80 42688 51907 62092 68746 120874 137277 169618 183113 195857 242201

>80 48269 58841 70492 78105 139897 159057 195603 211364 226250 280382



18-35 12908 14549 16715 18129 28627 31613 43946 46402 48721 57155

36-45 13412 15177 17443 18923 30324 33514 46521 49145 51623 60635

46-50 16094 18526 21543 23514 38016 42362 56769 60343 63719 75996

51-55 18487 21480 25137 27525 44901 50250 66137 70537 74693 89804

56-60 21555 25288 29755 32674 54070 60741 78708 84194 89378 108221

61-65 26605 31604 37438 41249 69429 78345 99556 106890 113817 139010

66-70 33404 40117 47806 52830 89903 101828 127260 137069 146335 180026

71-75 38840 46849 55940 61879 106528 120814 150264 162016 173116 213478

76-80 44898 54414 65133 72137 125648 142724 176247 190295 203564 251812

>80 50479 61348 73533 81495 144671 164504 202231 218547 233957 289993



18-35 15297 15929 18363 19953 31263 34588 47807 50543 53126 62520

36-45 15626 16462 18976 20619 32783 36284 50154 53035 55756 65650

46-50 18483 19904 23191 25338 40652 45337 60629 64483 68124 81361

51-55 21051 22951 26900 29479 47712 53428 70226 74928 79368 95519

56-60 24162 26783 31547 34659 56926 63971 82854 88648 94121 114024

61-65 29213 33099 39229 43235 72285 81575 103702 111343 118562 144812

66-70 36012 41613 49598 54816 92759 105058 131406 141522 151079 185828

71-75 41446 48344 57731 63865 109382 124044 154410 166470 177860 219281

76-80 47504 55908 66924 74122 128502 145954 180392 194748 208309 257615

>80 53086 62844 75325 83481 147525 167733 206377 223001 238702 295795



18-35 17,181 18,271 21,200 23,115 35,722 39,674 54,031 57,282 60,350 71,510

36-45 17,510 18,804 21,814 23,780 37,243 41,371 56,378 59,774 62,980 74,641

46-50 20,368 22,246 26,028 28,499 45,111 50,423 66,853 71,222 75,349 90,352

51-55 22,936 25,293 29,737 32,640 52,171 58,514 76,450 81,667 86,593 104,510

56-60 26,046 29,125 34,384 37,820 61,385 69,057 89,078 95,387 101,345 123,015

61-65 31,097 35,441 42,067 46,396 76,744 86,661 109,926 118,082 125,787 153,803

66-70 37,896 43,955 52,436 57,977 97,218 110,144 137,631 148,262 158,303 194,819

71-75 43,330 50,686 60,569 67,026 113,842 129,130 160,634 173,209 185,085 228,272

76-80 49,388 58,250 69,762 77,283 132,961 151,040 186,617 201,487 215,533 266,606

>80 54,970 65,186 78,163 86,642 151,984 172,819 212,602 229,740 245,926 304,785



18-35 19,065 20,612 24,038 26,276 40,182 44,760 60,256 64,021 67,575 80,501

36-45 19,394 21,146 24,651 26,941 41,702 46,457 62,603 66,513 70,204 83,632

46-50 22,252 24,588 28,866 31,660 49,570 55,509 73,078 77,961 82,573 99,343

51-55 24,820 27,635 32,575 35,801 56,630 63,600 82,675 88,406 93,817 113,500

56-60 27,930 31,467 37,222 40,981 65,844 74,143 95,303 102,126 108,570 132,006

61-65 32,981 37,782 44,904 49,557 81,203 91,747 116,151 124,821 133,011 162,793

66-70 39,780 46,297 55,274 61,138 101,677 115,230 143,855 155,001 165,527 203,809

71-75 45,214 53,028 63,407 70,187 118,301 134,216 166,859 179,948 192,309 237,263

76-80 51,272 60,592 72,600 80,444 137,420 156,126 192,841 208,226 222,757 275,597

>80 56,854 67,528 81,000 89,803 156,443 177,906 218,826 236,479 253,150 313,776



18-35 11819 12983 14806 15995 26304 28960 40723 42908 44972 52473

36-45 13566 14873 17048 18470 30725 33951 47207 49860 52366 61478

46-50 17165 19085 22180 24202 40569 45241 60525 64367 67996 81194

51-55 20555 22985 26886 29435 49765 55727 73336 78242 82876 99724

56-60 25134 28274 33249 36500 62414 70131 91110 97458 103453 125256

61-65 32227 36604 43304 47681 82503 93052 119039 127717 135913 165718

66-70 42563 48604 57834 63864 111270 125931 158668 170729 182122 223546

71-75 52369 59643 71109 78599 138131 156517 196404 211530 225815 277763

76-80 62390 71112 84974 94031 166752 189218 235913 254394 271850 335324

>80 72026 82043 98146 108667 195795 222365 276222 298080 318724 393796



18-35 13489 14822 17021 18458 29811 32942 45711 48288 50722 59569

36-45 15118 16583 19105 20752 33984 37648 51877 54890 57736 68085

46-50 18834 20924 24396 26664 44075 49221 65513 69748 73746 88289

51-55 22342 24954 29262 32078 53517 59995 78644 83973 89006 107309

56-60 26949 30275 35666 39188 66228 74470 96497 103276 109680 132963

61-65 34042 38605 45720 50369 86317 97391 124426 133536 142139 173423

66-70 44378 50606 60250 66552 115084 130269 164055 176549 188347 231253

71-75 54184 61644 73524 81287 141945 160855 201791 217347 232040 285470

76-80 64206 73113 87390 96719 170566 193556 241300 260214 278076 343031

>80 73840 84044 100563 111355 199608 226703 281609 303897 324949 401503



18-35 15517 17119 19804 21558 34186 37930 51828 54908 57817 68393

36-45 17002 18712 21681 23621 38045 42270 57583 61059 64342 76280

46-50 20863 23221 27179 29764 48451 54211 71628 76366 80842 97114

51-55 24515 27417 32252 35409 58210 65349 85170 91044 96591 116762

56-60 29160 32781 38707 42579 71000 79917 103125 110459 117385 142574

61-65 36252 41112 48761 53759 91089 102836 131055 140718 149846 183034

66-70 46590 53113 63291 69943 119856 135716 170685 183730 196054 240864

71-75 56394 64151 76565 84677 146717 166302 208419 224531 239747 295081

76-80 66415 75619 90431 100110 175338 199002 247930 267396 285782 352642

>80 76051 86551 103604 114746 204380 232149 288237 311081 332656 411113



18-35 17907 19877 23154 25297 39433 43926 59071 62766 66257 78947

36-45 19216 21266 24780 27075 42905 47818 64325 68367 72184 86067

46-50 23253 25979 30530 33502 53698 60206 78873 84226 89282 107668

51-55 27079 30379 35855 39431 63844 71791 92914 99453 105628 128085

56-60 31766 35794 42372 46670 76732 86470 110996 119007 126574 154088

61-65 38858 44124 52427 57852 96819 109390 138924 149266 159033 194550

66-70 49196 56124 66957 74036 125587 142270 178554 192278 205241 252380

71-75 59001 67164 80232 88770 152449 172856 216290 233079 248934 306596

76-80 69023 78632 94097 104202 181069 205555 255799 275943 294971 364157

>80 78658 89563 107269 118838 210110 238703 296106 319629 341843 422628



18-35 19791 22219 25992 28458 43893 49012 65296 69505 73480 87938

36-45 21101 23608 27618 30236 47364 52904 70549 75106 79408 95057

46-50 25137 28320 33368 36663 58158 65292 85097 90965 96506 116659

51-55 28963 32721 38693 42592 68303 76877 99138 106192 112852 137075

56-60 33650 38136 45210 49831 81191 91556 117221 125746 133798 163079

61-65 40743 46466 55265 61013 101278 114476 145148 156005 166257 203541

66-70 51080 58466 69795 77197 130047 147356 184778 199017 212465 261371

71-75 60886 69505 83070 91931 156908 177942 222514 239818 256158 315587

76-80 70907 80974 96935 107363 185529 210641 262023 282682 302194 373147

>80 80542 91905 110107 121999 214570 243789 302330 326368 349067 431619

The premium mentioned is annual premium.All premium are inclusive of applicable Goods and Services TaxA family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policyunder individual sum insured plan

2 Year Premium2 Year Individual Premium (Inclusive of goods & services tax)




0-16 13416 15281 17295 18613 27564 30106 41277 43368 45343 52525

17 14182 16228 18439 19885 30883 33910 45794 48283 50634 59182

18-34 14949 17175 19584 21157 34203 37713 50311 53199 55925 65839

35 15658 18030 20597 22273 36292 40072 53368 56477 59414 70092

36-44 16366 18885 21610 23390 38381 42431 56424 59756 62902 74345

45 18605 21707 25063 27256 44976 50013 65228 69372 73287 87520

46-49 20844 24529 28516 31122 51572 57596 74032 78988 83672 100696

50 22815 26989 31501 34451 57419 64291 82024 87676 93018 112434

51-54 24787 29449 34486 37780 63267 70987 90016 96365 102364 124173

55 27564 32902 38674 42447 71619 80540 101476 108813 115746 140951

56-59 30341 36356 42863 47114 79970 90092 112936 121262 129128 157728

60 35013 42196 49968 55045 94177 106378 132219 142255 151735 186207

61-64 39684 48037 57073 62976 108385 122663 151502 163248 174342 214686

65 45973 55913 66665 73689 127323 144385 177128 191164 204421 252625

66-69 52263 63788 76256 84402 146262 166106 202755 219080 234500 290565

70 57289 70016 83779 92773 161640 183668 224035 242156 259272 321508

71-74 62315 76243 91302 101144 177018 201230 245315 265232 284043 352451

75 67921 83240 99806 110631 194701 221495 269348 291390 312208 387910

76-79 73526 90237 108309 120118 212385 241761 293382 317548 340373 423369

80 78688 96652 116081 128775 229983 261907 317418 343681 368486 458686

> 80 83850 103066 123853 137432 247581 282053 341454 369815 396600 494003

2 Year Family Floater Premiums (Inclusive of goods & services tax)




18-34 20127 22666 25771 27802 44866 49253 69984 73596 77008 89410

35 20727 23400 26636 28752 46726 51350 72747 76552 80145 93212

36-44 21326 24134 27501 29701 48587 53447 75509 79507 83282 97013

45 23674 27077 31103 33733 55409 61293 84607 89448 94019 110640

46-49 26023 30020 34706 37764 62231 69139 93705 99389 104755 124267

50 28102 32598 37839 41261 68308 76097 101993 108401 114453 136458

51-54 30181 35177 40972 44759 74384 83055 110280 117413 124150 148650

55 32984 38662 45197 49467 82793 92675 121814 129941 137620 165539

56-59 35788 42146 49421 54176 91202 102294 133347 142470 151091 182429

60 40460 47988 56527 62107 105409 118578 152630 163465 173699 210909

61-64 45131 53830 63634 70038 119616 134862 171913 184460 196307 239389

65 51420 61704 73224 80751 138555 156585 197540 212375 226385 277329

66-69 57710 69579 82814 91464 157493 178308 223166 240291 256462 315269

70 62736 75806 90339 99835 172871 195868 244446 263366 281234 346211

71-74 67763 82033 97863 108206 188249 213429 265726 286440 306006 377154

75 73368 89030 106366 117693 205933 233696 289760 312600 334170 412613

76-79 78973 96028 114870 127180 223617 253963 313794 338759 362335 448073

80 84135 102442 122640 135837 241213 274109 337830 364891 390449 483390

> 80 89297 108857 130411 144494 258810 294255 361866 391023 418562 518707



18-34 23879 26916 30922 33538 52960 58484 81301 85843 90134 105736

35 24346 27496 31595 34273 54530 60242 83682 88381 92818 108955

36-44 24812 28077 32269 35008 56100 62000 86063 90919 95502 112174

45 27293 31174 36061 39254 63214 70185 95543 101277 106691 126383

46-49 29775 34272 39854 43500 70329 78370 105022 111635 117881 140593

50 31988 37005 43179 47211 76697 85667 113688 121064 128031 153365

51-54 34202 39738 46504 50922 83066 92963 122353 130494 138181 166138

55 37039 43261 50775 55684 91548 102667 133981 143127 151765 183174

56-59 39876 46784 55047 60446 100030 112371 145609 155760 165349 200209

60 44548 52625 62153 68378 114237 128655 164894 176753 187955 228689

61-64 49220 58467 69260 76311 128444 144939 184178 197746 210562 257169

65 55509 66342 78850 87024 147383 166661 209805 225662 240641 295109

66-69 61798 74216 88440 97736 166321 188382 235432 253578 270720 333049

70 66826 80444 95964 106106 181699 205944 256710 276654 295492 363992

71-74 71853 86671 103489 114476 197077 223506 277988 299730 320264 394934

75 77458 93668 111992 123964 214763 243773 302022 325888 348428 430394

76-79 83062 100665 120496 133453 232448 264040 326056 352045 376593 465853

80 88224 107080 128266 142109 250044 284186 350092 378179 404707 501170

> 80 93386 113494 136037 150766 267641 304332 374128 404312 432820 536487



18-34 28299 29468 33971 36914 57837 63988 88442 93504 98283 115661

35 28604 29961 34538 37529 59243 65557 90613 95809 100716 118557

36-44 28908 30454 35105 38144 60649 67126 92784 98115 103148 121453

45 31551 33638 39004 42510 67927 75500 102474 108704 114589 135985

46-49 34194 36822 42903 46876 75206 83874 112163 119293 126030 150518

50 36570 39640 46334 50706 81736 91357 121041 128955 136431 163614

51-54 38945 42459 49764 54536 88267 98841 129918 138616 146831 176710

55 41823 46004 54063 59328 96790 108594 141599 151307 160478 193827

56-59 44700 49549 58361 64119 105313 118346 153279 163998 174124 210945

60 49372 55390 65468 72052 119520 134630 172564 184992 196732 239424

61-64 54044 61232 72574 79984 133727 150914 191848 205985 219340 267902

65 60333 69108 82166 90697 152666 172636 217475 233901 249418 305842

66-69 66622 76984 91757 101410 171604 194357 243101 261816 279496 343782

70 71649 83210 99280 109780 186981 211919 264380 284893 304269 374726

71-74 76675 89436 106803 118149 202357 229481 285658 307969 329042 405670

75 82279 96433 115307 127638 220043 249748 309692 334126 357206 441129

76-79 87883 103430 123810 137126 237728 270015 333726 360284 385371 476589

80 93046 109846 131581 145783 255324 290161 357762 386418 413485 511904

> 80 98210 116262 139351 154440 272921 310307 381798 412551 441598 547220



18-34 31785 33801 39221 42762 66086 73397 99958 105971 111648 132294

35 32089 34294 39788 43377 67493 74966 102129 108277 114081 135190

36-44 32394 34787 40355 43992 68899 76535 104300 110582 116513 138086

45 35037 37971 44254 48358 76177 84909 113989 121171 127954 152618

46-49 37680 41154 48152 52724 83455 93283 123679 131760 139395 167151

50 40055 43973 51583 56554 89986 100767 132556 141422 149796 180247

51-54 42431 46792 55014 60385 96516 108251 141433 151083 160196 193343

55 45308 50336 59312 65176 105039 118003 153114 163775 173843 210460

56-59 48186 53881 63611 69967 113563 127755 164794 176466 187489 227578

60 52858 59723 70717 77900 127770 144039 184079 197459 210097 256056

61-64 57529 65565 77824 85832 141977 160323 203363 218452 232705 284535

65 63818 73441 87415 96545 160915 182045 228990 246368 262783 322475

66-69 70108 81316 97007 107258 179854 203766 254617 274284 292861 360415

70 75134 87542 104530 115628 195230 221328 275895 297360 317634 391359

71-74 80160 93768 112053 123997 210607 238890 297173 320436 342407 422303

75 85765 100765 120556 133486 228292 259157 321207 346594 370571 457762

76-79 91369 107763 129060 142974 245978 279424 345241 372752 398736 493221

80 96532 114178 136830 151631 263574 299570 369277 398885 426850 528537

> 80 101695 120594 144601 160288 281170 319716 393313 425019 454963 563853



18-34 35270 38133 44470 48610 74336 82806 111473 118438 125013 148927

35 35575 38626 45037 49225 75742 84376 113644 120744 127445 151823

36-44 35879 39120 45605 49840 77148 85945 115815 123050 129878 154718

45 38522 42303 49503 54206 84426 94318 125505 133639 141319 169251

46-49 41165 45487 53402 58572 91704 102692 135194 144228 152760 183784

50 43541 48306 56833 62402 98235 110176 144071 153889 163161 196880

51-54 45916 51124 60264 66233 104766 117660 152949 163551 173561 209976

55 48794 54669 64562 71024 113289 127412 164629 176242 187208 227093

56-59 51671 58214 68861 75815 121812 137165 176310 188933 200854 244211

60 56343 64056 75967 83748 136019 153449 195594 209926 223462 272689

61-64 61015 69898 83073 91680 150226 169733 214879 230920 246070 301168

65 67304 77773 92665 102393 169165 191454 240505 258835 276148 339108

66-69 73593 85649 102256 113106 188103 213176 266132 286751 306225 377047

70 78620 91875 109779 121476 203480 230737 287410 309827 330999 407992

71-74 83646 98101 117302 129846 218856 248299 308689 332903 355772 438936

75 89250 105098 125806 139334 236542 268566 332723 359061 383936 474395

76-79 94854 112095 134309 148822 254227 288834 356757 385219 412101 509854

80 100017 118511 142080 157479 271823 308979 380792 411352 440215 545170

> 80 105181 124927 149850 166136 289420 329125 404828 437486 468328 580486



18-34 21866 24019 27391 29591 48663 53576 75338 79380 83198 97075

35 23482 25767 29465 31881 52752 58193 81335 85811 90038 105405

36-44 25097 27516 31540 34170 56841 62809 87333 92241 96878 113735

45 28427 31412 36286 39472 65947 73252 99652 105660 111335 131972

46-49 31756 35308 41032 44774 75053 83695 111971 119079 125792 150208

50 34891 38915 45386 49615 83559 93395 123822 131913 139556 167349

51-54 38027 42522 49739 54455 92065 103095 135672 144748 153321 184490

55 42262 47415 55625 60990 103766 116419 152113 162523 172355 208106

56-59 46497 52307 61511 67525 115467 129743 168554 180298 191388 231723

60 53059 60012 70812 77867 134049 150945 194388 208287 221414 269150

61-64 59620 67718 80113 88209 152631 172147 220223 236276 251440 306578

65 69181 78818 93553 103179 179240 202560 256879 276062 294183 360069

66-69 78742 89917 106994 118148 205850 232973 293536 315849 336925 413560

70 87812 100129 119272 131778 230696 261264 328441 353589 377341 463711

71-74 96882 110340 131551 145407 255543 289556 363347 391330 417758 513862

75 106152 120949 144377 159683 282017 319805 399893 430980 460340 567106

76-79 115422 131557 157203 173958 308491 350053 436439 470630 502922 620349

80 124335 141668 169386 187496 335355 380714 473725 511039 546281 674436

> 80 133249 151780 181570 201035 362220 411376 511010 551447 589639 728522



18-34 24955 27420 31489 34147 55150 60943 84566 89333 93835 110203

35 26462 29049 33417 36269 59010 65296 90269 95440 100324 118080

36-44 27968 30678 35344 38390 62871 69649 95972 101547 106812 125957

45 31406 34693 40239 43859 72205 80354 108585 115290 121621 144646

46-49 34843 38709 45133 49328 81540 91059 121199 129034 136430 163334

50 38087 42437 49634 54336 90273 101025 133345 142192 150546 180928

51-54 41332 46164 54134 59344 99007 110990 145491 155350 164662 198521

55 45593 51086 60058 65921 110764 124379 162005 173205 183785 222251

56-59 49855 56008 65983 72498 122522 137769 178520 191060 202908 245981

60 56417 63714 75282 82840 141105 158971 204354 219051 232932 283407

61-64 62978 71419 84582 93182 159687 180173 230189 247041 262956 320833

65 72539 82520 98022 108152 186296 210586 266845 286828 305699 374325

66-69 82100 93621 111463 123121 212905 240999 303502 326615 348442 427818

70 91170 103831 123741 136751 237752 269290 338407 364354 388858 477969

71-74 100240 114042 136020 150380 262599 297582 373313 402092 429274 528120

75 109510 124650 148846 164656 289073 327831 409859 441744 471858 581364

76-79 118780 135258 161672 178931 315547 358079 446405 481395 514441 634607

80 127692 145370 173856 192469 342411 388740 483690 521803 557799 688694

> 80 136604 155481 186041 206008 369275 419401 520976 562210 601156 742780



18-34 28707 31670 36638 39883 63244 70171 95882 101579 106961 126526

35 30081 33144 38373 41791 66814 74185 101206 107269 112996 133822

36-44 31454 34618 40109 43699 70384 78199 106529 112959 119032 141118

45 35026 38788 45196 49381 80009 89245 119521 127118 134295 160389

46-49 38597 42959 50282 55064 89634 100290 132512 141277 149558 179660

50 41975 46841 54974 60285 98661 110593 145038 154854 164126 197835

51-54 45353 50722 59666 65507 107688 120896 157564 168431 178693 216009

55 49649 55684 65637 72139 119519 134371 174173 186390 197928 239885

56-59 53946 60646 71608 78770 131350 147846 190782 204350 217163 263761

60 60506 68351 80908 89112 149933 169046 216616 232339 247189 301187

61-64 67067 76057 90208 99455 168515 190246 242451 260328 277214 338613

65 76629 87158 103648 114424 195124 220661 279109 300115 319957 392105

66-69 86191 98259 117088 129394 221733 251075 315767 339901 362700 445598

70 95260 108469 129367 143023 246580 279367 350671 377642 403116 495749

71-74 104328 118679 141645 156653 271426 307659 385575 415382 443532 545900

75 113599 129287 154471 170928 297901 337906 422123 455032 486114 599144

76-79 122869 139896 167297 185203 324375 368153 458670 494682 528696 652388

80 131782 150007 179482 198742 351239 398814 495954 535091 572055 706474

> 80 140695 160119 191667 212280 378103 429475 533238 575500 615414 760560



18-34 33127 36772 42835 46799 72952 81262 109282 116117 122575 146052

35 34339 38057 44339 48444 76163 84863 114142 121298 128057 152638

36-44 35550 39343 45843 50089 79374 88463 119002 126478 133540 159223

45 39284 43702 51161 56034 89358 99923 132458 141148 149356 179205

46-49 43017 48061 56480 61979 99342 111382 145915 155818 165172 199186

50 46557 52131 61405 67463 108726 122098 158903 169903 180292 218072

51-54 50096 56201 66331 72947 118111 132814 171891 183988 195412 236957

55 54432 61210 72360 79643 130032 146392 188617 202076 214787 261010

56-59 58767 66219 78389 86340 141954 159970 205343 220163 234162 285063

60 65328 73925 87690 96683 160534 181171 231176 248152 264187 322491

61-64 71888 81630 96991 107027 179115 202371 257010 276141 294211 359918

65 81450 92730 110431 121996 205726 232786 293667 315928 336953 413411

66-69 91012 103830 123871 136966 232337 263200 330325 355715 379696 466903

70 100082 114041 136150 150595 257183 291492 365231 393455 420112 517053

71-74 109152 124253 148428 164225 282030 319784 400137 431195 460529 567202

75 118423 134861 161254 178499 308504 350031 436683 470845 503112 620446

76-79 127693 145469 174080 192773 334978 380278 473229 510495 545696 673690

80 136605 155581 186264 206311 361841 410939 510513 550904 589053 727776

> 80 145516 165692 198448 219850 388704 441600 547797 591313 632410 781862



18-34 36613 41104 48086 52647 81202 90671 120797 128584 135939 162685

35 37825 42390 49589 54291 84413 94272 125657 133765 141422 169271

36-44 39036 43675 51093 55936 87623 97872 130516 138945 146904 175856

45 42770 48034 56411 61882 97608 109331 143973 153615 162720 195838

46-49 46503 52393 61730 67827 107592 120791 157430 168286 178536 215819

50 50043 56463 66656 73311 116976 131507 170418 182370 193656 234704

51-54 53582 60533 71581 78795 126361 142223 183406 196455 208776 253590

55 57918 65542 77610 85491 138282 155801 200132 214543 228151 277643

56-59 62253 70552 83639 92188 150204 169379 216858 232630 247526 301696

60 68814 78257 92940 102531 168784 190580 242691 260619 277551 339124

61-64 75374 85962 102241 112874 187365 211780 268524 288608 307575 376551

65 84936 97062 115681 127844 213976 242194 305182 328395 350318 430043

66-69 94498 108162 129122 142814 240587 272609 341840 368182 393060 483536

70 103568 118373 141400 156443 265433 300901 376746 405922 433476 533685

71-74 112638 128585 153679 170073 290280 329193 411651 443663 473893 583835

75 121908 139193 166505 184347 316754 359440 448197 483313 516476 637079

76-79 131179 149802 179331 198621 343228 389686 484743 522962 559060 690323

80 140090 159913 191514 212159 370091 420348 522027 563371 602417 744409

> 80 149002 170025 203698 225697 396954 451009 559311 603780 645774 798495

All premium rates are inclusive of 2 year premium discount and applicable Goods and Services TaxA family discount of 5% will apply if 2 members and 10% if 3 or more family members are covered in the same policyunder individual sum insured plan

• Loading We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). The maximum risk loading applicable for an individual shall not exceed above 100% per diagnosis / medical condition and an overall risk loading of over 150% per person. These loadings are applied from commencement date of the policy including subsequent renewal(s) with us or on the receipt of the request of increase in sum insured (for the increased sum insured).

Please Note. –1. Premium rates and policy terms and conditions are for standard healthy individuals. These may change post underwriting of proposal based on medical

tests (where applicable) and information provided on the proposal form. Please visit our nearest branch to refer to our underwriting guidelines, if required. Premium rates are subject to change with prior approval from IRDAI.

2. In a family floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. The 2 adults can be a combination of self, spouse and either set of dependent parents or parents in law. In an individual policy, a maximum of 4 adults and a maximum of 5 children can be included in a single policy. The 4 adults can be a combination of self, spouse and either set of dependent parents or parents in law.

AMHI

/MA/

H/00

02/0

122/

0720

14/P

CT/A

MHP

/BR/

V0.0

4/06

2017

Citibank is a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number CA0086. This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. Participation by the bank’s customers in an insurance product is purely on a voluntary basis. For more details on terms and conditions please read sales brochure carefully before concluding a sale. • Tax laws are subject to change • IRDAI Reg. No.: - 131 • CIN: U66030AP2006PLC051760 • UIN: IRDA/NL-HLT /AMHI/P-H/V.1/15/13-14 • JSA/M/C16/343

Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana. Corp. Office: 1st Floor, SCF -19, Sector - 14, Gurgaon - 122 001, Haryana. Regd. Office: Apollo Hospitals Complex, Jubilee Hills, Hyderabad - 500 033, Telangana. Tel: +91 124 4584333 Fax: +91 124 4584111• Toll Free: 1800 3000 1401 • Email: [email protected] • Website: www.apollomunichinsurance.com

Application Number. Specified Person Name Code Location This is an application for Insurance. Every Information this application seeks is important. Please read all questions and answer them carefully. You must provide complete and correct information. Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy even if it is issued. It is not obligatory for us to accept any risk or issue policy to anyone. Regulations mandate that the coverage can incept only after we have received the full amount of premium and have explicitly accepted the risk. We may apply a risk loading on the premium payable (based upon the declarations made in the proposal form and the health status of the persons proposed for insurance). Please note that We will issue Policy only after getting Your consent in case of risk loading. We are under no obligation to accept any proposal for insurance. If We accept a proposal for insurance, it shall be subject to the Policy terms and conditions and We shall have no liability to make any payment under the Policy if proposal is not accepted by us or you do not accept the terms of counter offer or premium is not received by Us in full and in time, or is not realised, or non-fulfillments of Pre Policy Checkup and/or additional information requested by us. To be filled by the BankCustomer Segment: CPC Citigold Citibanking Suvidha Others ( please mention)

To be filled by the CustomerPlease note all sections are mandatory (except for the sections marked*)

1. PROPOSER DETAILS

Name: (Mr./Ms./Mrs.) First Name Middle Name Last Name

AddressPin Code

District/City StateEmail id Date of Birth D D M M Y Y Y YSTD Code Landline MobileAnnual Income Marital Status Nationality

*Id Proof Type : PAN Passport Driving License Voter’s Card If Other, please specify

*Id Proof No.

Please circle against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the listed titles below, please tick against all the applicable heads. Head of State or of Government / Senior Politician / Senior Government / Judicial / Military Officer / Senior Executive of State-Owned Corporation / Important Political Party Official

2. PLAN DETAILSPlan Name: Apollo Munich Health Plan - Silver Gold Platinum Type of Policy: Individual Floater Policy Period: 1 Year 2 Year3. PROPOSED INSURED(S) DETAILS

S.No.Name of the Insured person

Relationship to Policyholder

Gender Date of Birth Height (cms) Weight (kgs)Sum insured*( in Rs.)

Premium( in Rs.)

1

2

3

4

5

6

Note:• The insured and his family cannot select sum insured across variants in a single policy/application• Children aged between 91 days and 25 years can be covered . If the child age is between 91 days

to 5 years, please confirm whether one of the parent is getting covered in the plan Yes No

Total premium including goods & services taxDeduct 5% family discount if 2 member and 10% if 3 or more member are covered in case of individual plan. The discount may change if there is a change in the number of members covered in the policy at renewal.

Total premium payable

* Family Floater policy will have same Sum Insured for all members

4. NOMINEE DETAILSIn the event of the death of an Insured Person any payment due under the Policy shall become payable to the nominee in accordance with the policy terms and conditions. The nominee must be an immediate relative of the Proposer. The nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself.Nominee Name Relationship to Proposer

Insured 1

Photo28mm(w) x 30mm(h)

Insured 2


Insured 3


Insured 4


Insured 5


Insured 6


*5. PHOTOGRAPHS Please paste the photographs in sequence [Insured 1, Insured 2, Insured 3, Insured 4, Insured 5 and Insured 6] as specified in section 3 of details of proposed to be insured

Apollo MunichHEALTH PLAN

6. MEDICAL QUESTIONNAIRE (Medical & Life Style Information (Declaration))

Have you or any other member(s) proposed to be insured under this policy ever suffered from or are suffering from any of the following:

Insured 1

Insured 2

Insured 3

Insured 4

Insured 5

Insured 6

• Arthritis, disorders of the spinal cord or vertebral column for example slipped disc. £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Circulatory disorder, heart condition, paralysis of any kind, Haematological (blood) disorder £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Tumour or cancer of any kind, Diabetes, high blood pressure, allergies £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Disorders of the stomach / large or small intestine, hernia of any kind, haemorrhoids £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Nervous disorder, fainting episode, blackouts, fits, mental condition £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Respiratory disorder, urinary disorder, varicose veins £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N• Any diseases or injury requiring surgical or medical treatment £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £NHave you or any other member proposed to be insured under this policy sought medical advice in past 10 years or been advised or awaiting any treatment medical or surgical due to any of the diseases/conditions listed above or otherwise or attended follow up for any disease / condition / ailment/ injury / addiction (except for infrequent common illness for example common cold, loose motions, cough and cold, headaches, acidity)?

£Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N

Does your or any of the person proposed under this policy’s occupation or nature of job involve working in military or paramilitary forces, security forces, merchant navy or shipping, mines, electrical, aviation (flying), Oil or natural gas production or refining, explosive units or chemical industry or metal industry; working at heights (above or underground/sea level); handling of heavy machinery or hazardous materials; driving of heavy motor vehicles or significant manual labor?

£Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N

Is any of the insured pregnant? If yes please mention the expected date of delivery £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N £Y/ £N

To be filled if any of the answers to above questions is answered as Yes

Insured Person Name and details of Illness/ Medicine/Test/Surgery/Condition Diagnosis Date or Date of last consultation Details if inpatient/ outpatient was given

To provide additional information for other insured member(s), please provide details in above format on an extra sheet duly signed.

7. PORTABILITY I want to avail portability benefit ? Yes No (if yes, please fill the portability form and submit portability documents)

8. EXISTING/PREVIOUS INSURER DETAILS

Policyholder Name Policy No./Application No. Insurer

Period of Insurance Sum Insured(Rs.)

Claims lodged during the preceding yearsFrom To

D D M M Y Y D D M M Y Y

9. PREMIUM PAYMENT DETAILS

Instrument (Credit Card,Bank Account) Instrument Number Instrument Date Name of Payor Bank Name IFSC Code Amount ( Rs.)

NA NA Citibank

In case Premium is more than Rs.50,000, please provide PAN details.

Section 41 of Insurance Act 1938 as amended by Insurance Laws Amendment Act, 2015 (Prohibition of Rebates):No person shall allow or offer to allow, 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 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 insurers. Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees.10. EXCLUSIONSFollowing is an outline of the main exclusions below. Please refer policy wordings for detailed exclusions before purchasing this policy. Any illness/ disease/ injury pre-existing before the inception of the policy for the first 2/3 years, Non-allopathic treatment, , cosmetic aesthetic, dental treatment and obesity-related treatment, Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury, Medical expenses incurred during the first 30 days of inception of the policy, except those arising out of accidents, 2 years waiting period for the specified illnesses/ surgeries. This exclusion doesn’t apply for subsequent renewals without a break, Congenital disease, genetic disorders, stem cell implantation, War, riot, strike, nuclear weapons induced hospitalisation, any hazardous or dangerous or adventurous activities, Psychiatric, mental or nervous disorders, Parkinson and Alzheimer’s disease, measures primarily for diagnostic, X-ray or laboratory examinations which are not consistent with or incidental to the diagnosis and treatment, general debility or exhaustion, any treatment that is not of a reasonable cost, not medically necessary; drugs or treatments which are not supported by a prescription, crutches or any other external appliance and/or device used for diagnosis or treatment.

11. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS TO BE INSURED•I/ We 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/We am/are 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 Insurance Company and that the policy will come into force only after full receipt of the premium chargeable. • I/ We further declare that I/We 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/We declare and consent to the company seeking medical information from any hospital who at any time has attended on the life to be insured/proposer or from any past or present employer concerning anything which affects the physical and mental health of the life to be assured/proposer and seeking information from any Insurance company to which an application for insurance on the life to be assured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement. • I/ We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/ or Regulatory Authority. I understand that the AMHI may terminate the policy immediately, on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by any Insured Person or anyone acting on policy holder’s behalf or on behalf of an Insured Person upon 30 days’ notice by sending an endorsement to Insured Person’s address shown in the Schedule without refund of premium. I confirm that I have read the brochure and understood all the terms and conditions, coverage’s, and exclusion (related to: pre-existing diseases, waiting period and exclusion) and I accept them. I understand that Citibank N.A. will earn 15% as commission on this policy in their capacity as the licensed Corporate Agent of Apollo Munich Heath Insurance Company Limited.

Signature of Proposer: Date: Time: Place:

For detailed terms and conditions, please refer insurance policy document.

12. VERNACULAR DECLARATIONCertification in case the proposer has signed in vernacular (to be witnessed by someone other than agent/employee of the company):

Name of Proposer:

The content of this form and its particulars have been explained by me in vernacular to the proposer who has understood and confirmed the same.

Signature of Proposer: Signature of the witness:

Date: Place Name of the witness:

D D M M Y Y

AMHI

/PR/

H/00

34/0

122/

0720

14/P

Citibank is a licensed corporate agent of Apollo Munich Health Insurance Company limited under the composite license number CA0086. This Insurance policy is offered and underwritten by Apollo Munich Health Insurance Company limited. Participation by the bank’s customers in an insurance product is purely on a voluntary basis. For more details on terms and conditions please read sales brochure carefully before concluding a sale. • Tax laws are subject to change • IRDAI Reg. No.: - 131 • CIN: U66030AP2006PLC051760 • UIN: IRDA/NL-HLT /AMHI/P-H/V.1/15/13-14

Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon - 122 016, Haryana. Corp. Office: 1st Floor, SCF -19, Sector - 14, Gurgaon - 122 001, Haryana. Regd. Office: Apollo Hospitals Complex, Jubilee Hills, Hyderabad - 500 033, Telangana. Tel: +91 124 4584333 Fax: +91 124 4584111• Toll Free: 1800 3000 1401 • Email: [email protected] • Website: www.apollomunichinsurance.com

Documents

Apollo Munich HEALTH PLAN - Citi Bank · 8) Maternity benefit Not covered Normal or Caesarean Delivery Rs. 50,000* (*Including Pre/Post Natal limit of Rs. 3,500 and New Born limit