1. Coverage y ou can depend on, f or those who depend on y ou. PERSON AL ACCIDENT IP A - 2 For internal reference only

3. HDFC ERGO General Insurance Company Limited PERSONAL ACCIDENT INSURANCE - PROPOSAL FORM (All fields are mandatory and fill in CAPIT ALS only) Plan 2 (for internal reference only) PREMIUM DET AILS & POLICY PERIOD SOURCES OF FUND Name of Proposer Primary Insured Occupation Sex Clerical / Administrative Male Professional - Service / Business Engineer / W orker / Supervisor Driver/Daily W age Labourer (Persons e ngaged in milit ary ser vice, pr ofessional sports, mine w orkers, fr ee fig hters, w ater v essel cr ew , oil feild/rig w orkers, s tructural w orkers, windo w cleaner s, junk/ salvage workers, saw mill workers, security guards and similar hazardous occupation are excluded under the plan.) Address Street Name City Pin code State T el. (Res.) (Of f.) Mobile Email Amount ( ) ` Annual Gross Income ( ) ` Salary Business Other (Please Specify) Rupees (in words) (First Name) (First Name) (Middle Name) (Middle Name) (Last Name) (Last Name) CUST OMER INFORMA TION STD Code Please fill in your payment details for either Credit Card or Cheque option C R E D I T C A R D V isa Master Card Expiry Date Credit Card No. C H E Q U E : Please pay by crossed cheque (Account Payee Only) in the name of “HDFC ERGO General Insurance Company Limited”. M M Y Y Y Y ACKNOWLEDGEMENT – CUST OMER COPY Please retain this counterfoil for your records *Sourcing Channel / Agent / Broker Name *Sourcing Branch (City) STD Code Female (Figures in Rupees. All Premiums are Excluding GST) BANK ACCOUNT DET AILS PREMIUM P A Y ABLE 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. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. T rade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Personal Accident Insurance - IRDA/NL-HL T/HDFC-ERGOGI/P-H/V .I/257/13-14. UID:2990. PREMIUM P A Y ABLE Self Plan Self Plus Dependent Parents - Add-on Self & Family Plan Self & Family Plus Dependent Parents - Add-on 2.5 Lakh SI 612 1,487 1,459 2,334 969 1,844 2,227 3,102 1,327 2,202 2,998 3,873 1,938 2,812 4,448 5,323 2,653 3,528 5,990 6,865 5 Lakh SI 7.5 Lakh SI 10 Lakh SI 15 Lakh SI 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 Applicable rate of service tax will be charged on above premium

4. ACKNOWLEDGEMENT – CUST OMER COPY Please retain this counterfoil for your records (On behalf of HDFC ERGO General Insurance Company Limited) This is a t emporary r eceipt and does not mean c ommencement of the policy c ontract. HDF C ER GO Gener al Insur ance Compan y Limit ed is not liable f or an y inciden ts be tween the tme tha t the premium amount is received and policy issuance. The policy issuance/validity of receipt is subject to clearing of the cheque or credit card mandate. The policy can be issued once HDFC ERGO General Insurance Company Limited receives completed form and premium payment. Received from Mr ./Mrs./Ms. or M/s. Proposal from alongwith cheque/credit card mandate towards premium for Personal Accident Insurance Amount ( `) by Cheque No./Credit Card No. with Bank branch. Stamp & Signature by Co. Agent / Authorised Personnel PLAN BENEFITS SI – Sum Insured. F or Hospit al Cash, there is a time deductible of 3 days. P OLICY H IGHLIGHTS : L O W C OST A CCIDENT C OVER F OR Y OUR FAMIL Y • Broken bones coverage for parents up to 70 years. • 100% cover for spouse on all benefits under Family Plan. • Includes c over f or br oken bones, ambulance c osts, burns, per sonal acciden ts worldwide as well as Hospital Cash (both sickness & accidental injury). • Range of Sum Insured plans from Rs. 2.5 lakh to 15 lakh cover . • No medical or health check -up r equired. • A vailable to anyone up to 65 years and also for parents up to 70 years. • Easy payment – by cheque or credit card. • Policy becomes ef fective in 15 days after receipt of payment & accurately filled-in proposal form by HDFC ERGO General Insurance. LG Code Account No. (to be debited) LC Code Promo Code Place Date Signature of Person to be Insured Do y ou ha ve an y P ersonal Ac cident Insur ance w ith HD FC ER GO G eneral Insur ance or an y othe r insur ance c ompany? Provide d etails b elow ( atach sep arate s heet i f r eqd.) Non-disclosure or misrepresen taton of the abo ve inf ormaton, whe ther deliberat e or not, shall mak e this policy v oidable at the Compan y op ton and no claim shall be admit ed under this policy . DECLARA TION • Protects the entre family (spouse, children and dependent parents) at minimum cost. D D D D D D D D D D D D M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Relationship of Nominee to Insured Person Name of Nominee Existing Injury/ Disability /Sickness (attach separate sheet if required) Annual Gross Income ( ) ` Date of Birth First Name of Insured Person Surname of Insured Person SELF SPOUSE P ARENT P ARENT CHILD CHILD Please provide the information below for persons to be covered (Only immediate family members) FA M I L Y P L A N B E N E F I T S Accidental Dea th – Spouse 100% & Childr en 10% (ma x. 2) Permanent T otal Disability – Spouse 100% & Childr en 10% (ma x. 2) Broken Bones – Spouse 100% & Childr en No P ay -out Ambulance Cos ts – Same En titlement t o All F amily Member s Burns – Spouse 100% & Childr en No P ay -out Hospital Cash (Acciden ts & Sickness) – Spouse 100% & Childr en 50% AD D -O N B E NEFITS – D E PENDENT P A RENTS Accidental Death 250,000 250,000 25,000 250,000 250,000 50,000 250,000 250,000 75,000 250,000 250,000 50,000 250,000 250,000 50,000 Permanent T otal Disability Broken Bones B ENEFITS – S ELF P LAN 2.5 L AKH S I 5 L AKH S I 7.5 L AKH S I 10 L AKH S I 15 L AKH S I Accidental Death 250,000 500,000 750,000 1,000,000 1,500,000 Permanent T otal Disability 250,000 500,000 750,000 1,000,000 1,500,000 Broken Bones 25,000 50,000 75,000 100,000 150,000 Burns 12,500 25,000 37,500 50,000 75,000 Ambulance Costs 1,500 1,500 1,500 1,500 2,000 Hospital Cash (Accidents & Sickness) 250/day 250/day 250/day 500/day 500/day Name of Insurance Company Accidental Death Sum Insured Policy Number Policy Period Benefts Covered ` ` D D M M Y Y Y Y ¡ I/W e understand that a charge may be levied on each instruction payment rejected due to lack of funds. ¡ I/W e understand that any charges levied (including commission, postage & stamp duty) may be debited to me/us. ¡ HDFC ERGO General Insurance Company Limited will not be held liable for any subsequent deduction on the payment instructions further to cancellation of the policy . ¡ 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. ¡ 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 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 authorize HDFC ERGO General Insurance and associate partners to contact me via email, phone, SMS. ¡ I/W e accept the T erms and Conditions of the insurance policy . ¡ 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 . ¡ The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium payment does not tantamount to the acceptance of the Proposal for insurance by HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. ¡ I/W e hereby authorise HDFC ERGO General Insurance Company Limited to use relevant data for marketing purposes either directly or through third party agents. 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 General Insurance Company Limited, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO General Insurance Company Limited 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 ERGO General Insurance Company Limited and the issuance of a Policy of Insurance by HDFC ERGO General Insurance Company Limited, the Policy Ef fective Date shall commence fifteen (15) days from the date of receipt of the premium by HDFC ERGO General Insurance Company Limited. HDFC ERGO General Insurance Company Limited 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.) 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 filed with the Income T ax Department. 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. 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. Mode of Payment : Cheque, Demand Draft and Credit Card. Payment by cash will not be accepted . (Figures in Rupees. All Premiums are Excluding GST) Printing Code: IP A2/BPF/0025/OCT19

2. An accident can strik e a t anytime. It tak es onl y a second... but the ef fects can last a lifetime! In such cases it is utmost important to ensur e tha t y our f amil y doesn ’t ha ve to f ace ad ditional bur den of managing their da y-to-da y basic needs. Tha t ’ s wher e HDFC ERGO P er sonal Accident P olic y r eassur es y our f amil y of the ad ded pr otection & financial security tha t the y r equir e a t such a cr ucial time. PREMIUM P A Y ABLE Self Plan Self & F amil y Plan Self Plus Dependent Par ents -Ad d -on Self & F amil y Plus Dependent Par ents Ad d-on WHA T IS CO VERED ? Accidental Death: Pa ys up to 100% of the Sum Insur ed if bodil y injur y r esults in dea th fr om an accident Per manent Disability: Pa ys up to 100% of the Sum Insur ed if bodil y injur y r esults in permanent disa bility due to an accident Bur ns: Pa ys up to ` 75,000 if an accident r esults in hospitaliza tion and tr ea tment f or burns Hospital Cash (Accidents & Sickness): Pa ys up to ` 500 a da y* f or upto a maximum of 45 da ys (i.e. up to ` 22,500) in case of hospitaliza tion fr om accident or sickness. Fir st 3 da ys of hospitaliza tion not included Brok en Bones: Pa ys up to ` 1.5 lakh (or a f la t ` 50,000 f or par ents) if an accident r esults in br ok en bones Anti-R ebating War ning : As per Section 41 of the Insurance Act 1938, as amended, the practice of r eba ting is pr ohibited, as f ollows: No per son shall allow or of fer to allow , either dir ectl y or indir ectl y , as an inducement to any per son to tak e out or r ene w or contin ue an insurance polic y in r espect of any k ind of risk r ela ting to li ves or pr operty in India, any r eba te of the whole or part of the commission pa y a ble or any r eba te of the pr emium shown on the polic y , nor shall any per son tak ing out or r ene wing or contin uing a polic y accept any r eba te, except such r eba te as ma y be allowed in accor dance with the published pr ospectus or ta bles of the insur er . Viola tions of Section 41 of the Insurance Act 1938, as amended, shall be punisha ble with a fine which ma y extend to ` 10 Lakhs. Lia bility of the Company does not commence until the Company has accepted the pr oposal and the full pr emium has been paid. Disclaimer: The a bove inf orma tion is onl y indica ti ve in na tur e. F or details of the coverage and exclusions please r efer to the polic y wor dings. A pplica ble rate of ser vice tax will be char g ed on a bo v e pr emium KEY FEA TURES WHA T IS NO T CO VERED ? § Self inf licted injur y Par ticipa tion in a criminal act § Par ticipa tion in a hazar dous spor t § PREMIUM DET AIL S 2.5 Lakhs SI 612 1,459 1,487 2,334 5 Lakhs SI 969 2,227 1,844 3,102 7.5 Lakhs SI 1,327 2,998 2,202 3,873 10 Lakhs SI 1,938 4,448 2,812 5,323 15 Lakhs SI 2,653 5,990 3,528 6,865 Under this polic y , these include , but ar e not limited to: *F or up to 45 da ys , after 3 da ys of continuous hospitalization Other ex clusions a ppl y . Please r ead the polic y contract f or a full list of our ex clusions, terms and conditions Printing Code: IP A2/BPF/0025/OCT19 Ambulance Costs: Pa ys up to ` 2000 towar ds the r eimbur sement of costs f or ambulance charges T err orism § W ar or ci vil war § Into xica tion § AIDS/ HIV § § Pr otects the entir e f amil y (spouse , childr en and dependent par ents) a t minimum cost § Br ok en bones coverage f or par ents up to 70 y ear s § 100% cover f or spouse on all benefits under F amil y Plan § Includes cover f or br ok en bones, burns, ambulance costs, per sonal accidents wor ld wide as well as Hospital Cash (both sickness & accidental injur y) § R ange of Sum Insur ed plans fr om ` 2.5 lakh to ` 15 lakh cover § No medical or health check-up r equir ed § Open to any one up to 65 y ear s and par ents up to 70 y ear s § Life Long Rene wa bility § Easy pa yment - by Cheque or Cr edit Car d BENEFITS - SELF PL AN Accidental Dea th P ermanent T otal Disa bility Br ok en Bones Burns Ambulance Costs Hospital Cash (Accidents & Sickness) 2,50,000 2,50,000 25,000 12,500 1,500 250/da y 5,00,000 5,00,000 50,000 25,000 1,500 250/da y 7,50,000 7,50,000 75,000 37,500 1,500 250/da y 10,00,000 10,00,000 1,00,000 50,000 1,500 500/da y 15,00,000 15,00,000 1,50,000 75,000 2,000 500/da y ADD-ON BENEFITS (DEPENDENT P ARENTS) Accidental Dea th P ermanent T otal Disa bility Br ok en Bones 2,50,000 2,50,000 50,000 2,50,000 2,50,000 50,000 2,50,000 2,50,000 50,000 2,50,000 2,50,000 50,000 2,50,000 2,50,000 50,000 ** F AMIL Y PL AN BENEFITS Accidental Dea th Br ok en Bones Br ok en Bones - Spouse 100% & Childr en 10% (max. 2) - Spouse 100% & Childr en No Pa y-out - Spouse 100% & Childr en No Pa y-out P ermanent T otal Disa bility Ambulance Costs Hospital Cash (Accidents & Sickness) - Spouse 100% & Childr en 10% (max. 2) - Same Entitlement to All F amil y Member s - Spouse 100% & Childr en 50% TERMS & CONDITIONS Y ou ha ve a period of 15 da ys fr om the da te of r eceipt of the P olic y document to r e vie w the terms and conditions of this P olic y . If Y ou ha ve any objections to any of the terms and conditions, Y ou ha ve the option of cancelling the P olic y sta ting the r easons f or cancella tion and Y ou will be r efunded the pr emium paid by Y ou after adjusting the amounts spent on any medical check-up , stamp duty charges and pr oportiona te risk pr emium. Y ou can cancel Y our P olic y onl y if Y ou ha ve not made any claims under the P olic y . All Y our rights under this P olic y will immedia tel y stand extinguished on the fr ee look cancella tion of the P olic y . Fr ee look pr ovision is not a pplica ble and a vaila ble a t the time of r ene wal of the P olic y . FREE L OOK