I understand enrollment under the insurance plan is voluntary & I agree to enroll myself under Reliance general insurance Group Personal Accident Policy issued to Efaarms Solutions India Private Limited for covering their customers. I declare that I have made complete, true and correct disclosure of all the facts and circumstances and I have not withheld or suppressed any information that may be relevant and material to enable the insurance company to make an informed decision about the acceptability of the risk. Should any statements/s be found incomplete, false, incorrect I may be denied the cover or claim at any point in time. I understand that cover will not commence till the time Insurance Company issues a Certificate of Insurance. In case of any change in any of the statements made prior to acceptance of risk by the insurance Company, I undertake to inform the insurance company about the same.
1. I have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to abide by the same.
2. I agree and understand that this application is part of group personal accident policy no. 920292129140000063 and Issued to Efaarms Solutions India Private Limited for covering their account holders.
3. I understand that the information provided by me will form the basis of the insurance cover and is subject to the Board approved underwriting group personal accident policy of the insurance company and that the policy will come into force only after full receipt of the premium chargeable.
4. 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.
5. I declare that I 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.
6. I authorize the company to share information pertaining to my application including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and /or Regulatory Authority.
7. I understand that the group personal accident policy shall become void at the option of the company, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure of any material fact in the Application form/personal statement, declaration and connected documents or any material information having been withheld by me or anyone acting on my behalf.
8. Receipt of the Application by the Company shall not be construed as acceptance of my application. I hereby agree that the insurance coverage shall commence only on realization of full premium and on receipt of complete medical reports (wherever applicable) and subject to underwriting by the Company. The Company at its sole discretion reserves the right to accept or reject any application form without assigning any reason thereof.
9. I hereby declare that the person(s) proposed to be Insured would submit to medical examinations, before the nominated doctors of the Company, or undergo diagnostic or other medical tests, as suggested by the Company for its underwriting.
10. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.
11. I declare that i am not suffering from any pre-existing disease & if found that i have been suffering from any pre-exisitng disease post purchasing the policy, my insurance cover will be null & void.
12. I consent to receive information from the Company through physical, electronic or telecommunication means from time to time.
13. 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 authorised to propose on behalf of these other persons.
14. I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST.
15. I/We hereby confirm that the contents of the application and connected documents have been fully explained to me/us and I/We have fully understood the significance of the proposed contract.
