I hereby declare that:

1. I am in good health.
2. I perform all my routine activities independently.
3. I have never had any physical defect, deformity or disability #affecting to my day to day activities.
4. I have never suffered and am not currently suffering from:
   • High blood pressure, heart attack or any other heart disease;
   • Stroke, paralysis in any form or any other Cerebrovascular disease;
   • Diabities or any other Endocrinal Disease, Kidney Disease;
   • Any Chronic Liver Disease
   • Any Lung Disease ( eg., Chronic Obstructive Pulmonary Diseases, Parenchymal lung Disease, Pulmonary Embolism etc.), Blood Disorders, Gastro-Intestinal Diseases, or any other disorder of the bones, spine or muscle.
   • Any Cancer or Cancerous growth;
   • Any Mental or Psychiatric condition, any Genetic Disease or any disease related to central nervous system (disease related to brain); HIV / AIDS or AIDS related complications;
   • I have never undergone nor have I been advised to undergo any major surgical procedure.
   • In the last 2 years, I have not:
   • continuously hospitalized for more than 7 days (other than fractures of leg or arm);
   • undergone any investigations (including basic radiological and blood tests) other than normal Health Check-ups and Insurance Medicals;
   • Or had adverse result for any blood tests, X-Rays, ECG, Stress Test, Biopsies, CT Scan, MRI, Ultrasonography or 2D / 3D Echo etc.
5. I do not engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature.

#Disability means inability to function normally, physically or mentally

I further declare that the above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Kotak Mahindra Life Insurance Company Ltd [KLI]. I further hereby agree and give my consent to, the Policyholder for use of the contents of this declaration by KLI for examining and processing any claim arising, in respect of the insurance cover that may be provided to me under the referred group policy.

I hereby confirm that my intent to participate in the above plan for the Policyholder's customers is purely on a voluntary basis, and have further understood the terms and conditions of life insurance cover that maybe extended to me. I confirm and agree that the insurance cover, if provided, will be governed by the provisions of the Insurance Act 1938 and the Policy Contract under which the cover will be offered to me.

I hereby confirm that my intent to participate in the above plan for the Policyholder's customers is purely on a voluntary basis, and have further understood the terms and conditions of life insurance cover that maybe extended to me. I confirm and agree that the insurance cover, if provided, will be governed by the provisions of the Insurance Act 1938 and the Policy Contract under which the cover will be offered to me.

I agree and understand that if I contract any of the above diseases between submitting this document and the date of commencement of the cover, I shall not be covered under the policy. I have also not withheld any material information or suppressed any fact. I undertake to notify KLI ('The Company") of any change in my state of health or occupation or any decisions subsequent to the signing of this declaration form and before the acceptance of the risk by the Company.

I undertake to notify KLI ('The Company") of any change in my state of health or occupation or any decisions subsequent to the signing of this declaration form and before the acceptance of the risk by the Company.

I understand and agree that if any untrue statement be contained herein, I, my heirs, executors, administrators or assignees shall not be entitled to receive any benefits which may be provided to me on the faith of this declaration, including, inter alia the aforesaid insurance cover.

I understand and acknowledge that insurance cover shall be as per terms and conditions detailed in the Policy Contract issued by KLI in favour of the policyholder and that KLI's decision in respect of all aspects of the referred group life insurance plan shall be final & binding. I hereby agree to and authorize the Policyholder / my Doctor / Hospital / Local, State, Central authority / Dealer / Distributor /my Employer to divulge or convey any information or particulars relevant to this Form

Admission into the referred Group Insurance Policy to KLI at any point during the continuance of my cover hereunder including any claim under the said Policy. I also permit KLI to approach me directly for any clarification and / or other purposes.

I hereby declare, in case of fraud, misrepresentation and suppression of material facts the Certificate of Insurance shall be treated in accordance with the Sec 45 of the Insurance Act, 1938 as amended from time to time . I am aware that Section 41 & 45 of Insurance Act, 1938 are applicable to this contract.

Declaration by Member

I declare and confirm that the below statements are true and accurate:

• My age is between 18 years to 50 years as on today (i.e. date of purchase).
• I am not a Housewife or a student.
• My annual income is ……. and supporting income proof will be furnished to Kotak Mahindra Life Insurance Company in case of any such requirement.
• I am aware that I am eligible to purchase Kotak Group Secure One plan from only 1 Nreach online Services Pvt Ltd (XOXODay) A/C and I can buy only 1 policy with cumulative Sum assured of 10 Lakh through Nreach online Services Pvt Ltd (XOXODay) App. Kotak Mahindra Life Insurance Company is authorized to cancel policies purchased in my name from any other Nreach online Services Pvt Ltd (XOXODay) A/C. My nominee will not be entitled to receive any claim beyond 10 lakhs and cannot claim for any policy purchased form any other Nreach online Services Pvt Ltd (XOXODay) A/C. Policy coverage will start from T day (where T is the day on which I will submit the application, make payment via Nreach online Services Pvt Ltd (XOXODay) app).
• I am aware that I will receive the COI directly on my mobile no and/or email id registered with Nreach online Services Pvt Ltd (XOXODay) and same shall also be available for download after the payment of premium.
• I am aware that Nreach online Services Pvt Ltd (XOXODay) India Private Limited is the holder of the life insurance Master Policy issued by Kotak Mahindra Life Insurance Company Ltd for Kotak Group Secure One Plan and I will be a member of this group policy.
• I understand that benefits under this policy shall terminate, immediately if I fail to satisfy any of the eligibility criteria or cease to be a member of the group for whatsoever reason or cessation of relationship with MPH or if the due premium is not paid on the due date or within the grace period.
• I confirm that I have bought this policy to cover my own life and not bought for any other person. All other terms and conditions including those mentioned in the certificate of insurance will be applicable.
• The policy wordings for this product can be downloaded from insurer company website.