1. An investment to pr otect y our f amil y's futur e PERSON AL ACCIDENT IP A - 1 For internal reference only

4. Place: Date D D M M Y Y Y Y Signature of the Proposer (As per Bank Record) Do you have any Personal Accident Insurance with HDFC ERGO or any other Insurance company? Please provide details below (attach a separate sheet if required.) Name of Insurance Company Accidental Death Sum Insured Policy Number Policy Period ` ` Non-disclosure or misrepresentation of the above information, whether deliberate or not, shall make this policy voidable at the Company option and no claim shall be admitted under this policy . Benefits Covered ¡ I authorize HDFC ERGO General Insurance and associate partners to contact me via email, phone, SMS The acceptance of the Proposal for insurance shall be at the Company’ s sole and absolute discretion. In the event of acceptance of the Proposal for insurance by HDFC ERGO, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO along with the date from which the insurance cover shall become ef fective. The Proposer agrees that, in the event of acceptance of the Proposal for insurance by HDFC ¡ 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 declare and further consent to the company . seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/ proposer or from any past or present employer concerning anything which af fects 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/W e further declare that I/W e 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 accept the T erms and Conditions of the insurance policy . ¡ I/W e 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/W e hereby declare on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects to the best of my knowledge and that I/W e am/are authorized to propose on behalf of these other persons. ¡ The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO along with the premium payment does not tantamount to the acceptance of the Proposal for insurance by HDFC ERGO and does not result in a concluded contract of insurance. ERGO and the issuance of a Policy of Insurance by HDFC ERGO, the Policy Ef fective Date shall commence fifteen (15) days from the date of receipt of the premium by HDFC ERGO. HDFC ERGO shall not be liable for any claim in respect of an event giving rise to a claim covered under the Policy of Insurance that has occurred during this period of fifteen (15) days. Y our proposal form will be considered after HDFC ERGO General Insurance Company Limited receives premium payment. T o facilitate payments of the insurance premium to HDFC ERGO General Insurance Limited. The Maximum Compensation in respect of an Insured Person under the policy shall not exceed 5 times the Annual Income (as declared in the Proposal Form). Income proof for availing the compensation at the time of claim is mandatory . Income proof shall mean the previous year ’ s returns fled with the Income T ax Department. FRAUD W ARNING: Any person who, knowingly and with intent to defraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits. ANTI-REBA TING W ARNING: As per Section 41 of the Insurance Act 1938, as amended, the practice of rebating is prohibited, as follows: No person shall allow or of fer to allow , either directly or indirectly , as an inducement to any person to take out or renew or continue an insurance policy 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 prospectus or tables of the insurer . V iolations of Section 41 of the Insurance Act 1938, as amended, shall be punishable with a fine which may extend to ` 10 Lakhs. Mode of Payment: Cheque, Demand Draft & Credit Card. Payment by Cash will not be accepted. DECLARA TION HDFC ERGO General Insurance Company Limited. IRD AI Re g . No . 146. CIN: U66030MH2007PL C177117. Re gister ed & Cor pora te Of fice: 1st Floor , HDFC House, 165-166 Backba y Reclama tion, H. T . Par ekh Marg , Chur chg a te, Mumbai – 400 020. Customer Ser vice Ad dr ess: D-301, 3r d Floor , Eastern Business District (Magnet Mall), LBS Marg , Bhandup (W est), Mumbai - 400 078. Customer Ser vice No: 022 - 6234 6234 / 0120 - 6234 6234 | car e@hdfcerg o .com | www .hdfcerg o .com. F or mor e details on the risk f actor s, terms and conditions, please r ead the polic y document car efull y bef or e concluding a sale. T rade Log o displa y ed a bove belongs to HDFC Ltd and ERGO Interna tional AG and used by the Company under license. UIN: P er sonal Accident Insurance - IRD A/NL-HL T/HDFC-ERGOGI/P-H/V .I/257/13-14. UID No . 3002. hdfcerg o .com 1800 2666 400 HDFC ER GO Mobile App HDFC ER GO General Insurance Compan y Limited Printing Code:IP A1/BPF/0024/OCT19

3. STD Code First Name of Insured Person Surname of Insured Person Existing Injury/ Disability /Sickness (attach separate sheet if required) Date of Birth Name of Nominee Relationship of Nominee to Insured Person Self Spouse Dependent Dependent D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC1771 17. Registered & Corporate Of fice: 1st Floor , HDFC House, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor , Eastern Business District (Magnet Mall), LBS Marg, Bhandup (W est), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 - 6234 6234 | care@hdfcergo.com | www .hdfcergo.com. T rade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. HDFC ERGO General Insurance Company Limited PERSNAL ACCIDENT INSURANCE - PROPOSAL FORM (All fields are mandatory and fill in CAPIT ALS only) Plan 1 (for internal reference only) CUST OMER INFORMA TION PREMIUM DET AILS & POLICY PERIOD Name of Proposer: HDFC ERGO Location Code: Pre-Issuance: T ele sales BDR / TSE Code: SM Code: TL Code: Doc Ex code: HE SM Code: City: (*Mandatory field) EMI Option: Y es No Branch Sales Quality CVM DT W elcome call Post-Issuance: Customer Service: HDFC Bank of fice use only Application No. Occupation: Clerical/Administrative Professional - Service / Business Engineer/W orker/Supervisor Driver/Daily W age Labourer Persons engaged in military service, professional sports, mine workers, fire workers, fire fighters, water vessel crew , oil field/oil rig workers, structural workers, window cleaners, junk/salvage workers, saw mill workers, security guards and similar hazardous occupations are excluded under the plan. Address: City: Pin Code: State: T el. (Res.): (Of f.) Mobile: Email: Amount ( ` ) Rupees (in words) (First Name) (Middle Name) (Last Name) Sex: Male Female DSA MER HE Representative: SOURCES OF FUND Salary Business Other (Please Specify) STD Code Please provide the details of the persons to be covered Annual Gross Income ` Proposed Policy Period: D D M M Y Y Y Y to D D M M Y Y Y Y From Name of the Bank Account Holder: Name of Bank: I wish: MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank) IFSC Code ( 1 1 character code appearing on your cheque leaf): Any refund due on the premium payment / any payment/claims will be directly credited to my aforesaid Bank Account.* *As per the IRDAI, its mandatory that all payments made to the insured only through electronic mode. Bank Account No: Account: Savings Current Branch: BANK ACCOUNT DET AILS Cheque Please pay by crossed cheque (Account Payee Only) in the name of “HDFC ERGO General Insurance Company Limited”. Please fill in your payment details below for either Credit Card or Cheque option : Credit Card: V isa Master Card Expiry Date Credit Card No. M M Y Y Y Y Name of Bank: Branch and city: Cheque No. Amount ( ` ): Date: D D M M Y Y Y Y P AN No.

2. IP A Plan 1 (APPHC) Pr emium for 1 year with GST Sum Insur ed Self Plan Self + Spouse Self + Spouse + 1 Child Self + Spouse + 2 Children BOUND AR Y CONDITION KEY BENEFITS Of fer s 7 options fr om a minimum coverage of ` 15 Lakhs to a maximum of ` 1 Cr Age Criteria - 18 y ear s to 69 y ear s ` Accidental Death: 100% of the Sum Insur ed is paid in case of loss of life in an accident Per manent Disability: Pa ys a benefit up to the maximum Sum Insur ed, if the Insur ed is permanentl y disa bled due to an accident T emporar y T otal Disablement: Pa ys a week l y benefit upto maximum of 52 weeks if an accident causes disa blement tha t pr e vents the Insur ed per son fr om eng aging in or gi ving a ttention to his/her usual occupa tion. (1 week time deductible a pplica ble) Hospital Cash: Optional benefit pr ovides a dail y benefit of ` 1,000 up to a maximum of 30 da ys in case of hospitaliza tion due to an Accident Last Rites: Pa ys a benefit towar ds the cost of the funeral of the Insur ed per son, if an accident causes loss of life Brok en Bones: Pa ys up to the maximum Sum Insur ed in the e vent of bodil y injur y r esulting in br ok en bones due to an accident ` *F amily Co v er: 50% of the Sum Insur ed in case of Accidental Death or Per manent Disa bility of the spouse & 10% of the Sum Insur ed in case of Accidental Death or Per manent Disa bility of the childr en (max.2) Note: Co v erag e ’ s , ter ms and conditions and exclusions ar e only outlined briefly . F or complete details; please r efer to the polic y wordings KEY FEA TURES The cover pr ovided is a pplica ble 24 hour s a da y , 7 da y a week, 365/ 366 da ys of the y ear The indi vidual stands pr otected by this P er sonal Accident cover in India and any other loca tion wor ld wide Option to cover onl y “Self ” or “Self & F amil y i.e. Spouse + max 2 childr en” Easy pa yment by Cr edit Car d & Cheque No health check up r equir ed Cumula ti ve bon us of 5% incr ease in Sum Insur ed on r ene wals, a pplica ble to the basic Sum Insur ed f or Accidental Dea th & P ermanent Disa bility 5% NEGA TIVE LIST § Armed F or ces (Army/ Na vy/ Air F or ce) Para - militar y F or ces (BSF , RAF , CRPF , etc) § Pr ofessional Spor ts P er sons § Hazar dous Spor ts (Bungee jumping , J et-Sk iing , Para-gliding , etc) § Mer chant Na vy § Air line Pilots § Of f-shor e W or k er s (Oil rigs/ Drilling pla tf orms) § EXCL USIONS Bodil y Injur y / Sickness caused: Intentionall y § Due to Ci vil W ar or F or eign W ar § Under the inf luence of Alcohol /dr ug § Due to AIDS / HIV § Due to acti ve par ticipa tion in violent la bour disturbance / public disor der § On duty with militar y or police f or ce or paramilitar y org aniza tion § Due to par ticipa tion in hazar dous spor ts § PREMIUM DET AIL S 15 Lakhs 3325 4699 4699 4699 20 Lakhs 4209 6004 6004 6004 25 Lakhs 5089 7380 7380 7380 35 Lakhs 6865 10061 10061 10061 50 Lakhs 9504 14082 14082 14082 75 Lakhs 13917 20783 20783 20783 1 Cr 18535 26630 26630 26630 IP A Plan 1 (APPHC) Pr emium for 2 year with GST Sum Insur ed Self Plan Self + Spouse Self + Spouse + 1 Child Self + Spouse + 2 Children 15 Lakhs 6418 9069 9069 9069 20 Lakhs 8124 1 1588 1 1587 1 1587 25 Lakhs 9822 14243 14243 14243 35 Lakhs 13233 19417 19417 19417 50 Lakhs 18342 27179 27179 27179 75 Lakhs 26860 401 12 401 12 401 12 1 Cr 35773 51396 51396 51396 IP A Plan 1 (APPHC) Pr emium for 3 year with GST Sum Insur ed Self Plan Self + Spouse Self + Spouse + 1 Child Self + Spouse + 2 Children 15 Lakhs 9277 131 10 131 10 131 10 20 Lakhs 1 1743 16751 16751 16751 25 Lakhs 14199 20589 20589 20589 35 Lakhs 19128 28069 28069 28069 50 Lakhs 26515 39289 39289 39289 75 Lakhs 38828 57986 57986 57986 1 Cr 51714 74298 74299 74298 Submit all the r equisite documents a t the near est HDFC ERGO General Insurance Of fice. Email: car e@hdfcerg o .com Customer Ser vice No: 022 - 6234 6234 / 0120 - 6234 6234