1. FAMILY FLOATER MEDICLAIM Sum insured of ₹ 5 Lac & ₹ 10 Lacs only2. FAMILY DEFINITION : (1+5 ) maximum 6 members Proposer + Spouse ( Husband / Wife ) + 2 Dependent children up to 25 years of age + 2 Parents OR In-Laws (Any 1 set of Parents to be covered. Combination not allowed )3. INDIVIDUAL POLICY with Sum Insured of ₹ 2 Lacs available only for individuals BELOW 40 years

4. AGE LIMIT 0 to 80 years, renewable till LIFETIME5. PRE-EXISTING DISEASES are covered from Day One6. NO MEDICAL CHECK-UP required7. CASH LESS facility for more then 3200 hospitals8. All Internal congenital Diseases covered9. Domiciliary Hospitalisation Covered up to 20% of Sum Insured10. Maternity covered (₹ 30,000 for NORMAL & ₹ 35,000 for CAESARIAN Delivery) with 9 month waiting period .11. NEW BORN BABY covered from Day 1 subject to timely enrollment in JIO Policy (Only Reimbursement cases)12. Hospitalisation AYURVEDIC / HOMEOPATHIC / UNANI Treatment ₹10,000 Per claim (up to ₹20,000 per year)13. Hospitalization arising out of PSYCHIATRIC AILMENTS Covered up to ₹30,00014. Liability for Nasal Sinus Surgeries Covered up to ₹35,00015. Cyberknife treatment Covered with Co-pay of 50%16. Stem Cell Transplantation Covered with Co-pay of 50% 17. Cochlear Implant treatment Covered up to 50% of the Sum Insured18. As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption.19. DAY CARE PROCEDURES Covered as per Insurance company norms20. Emergency Ambulance charges up to ₹ 2,500 Per incidence21. 30 Days Pre Hospitalisation & 60 Days Post Hospitalisation expenses covered22. ROOM RENT & ICU CHARGES limitation Per Day (Inclusive of Nursing charges) :

23. CLAIM INTIMATION for all reimbursement claims have to be intimated within 7 days of ADMISSION23. CLAIM SUBMISSION of documents for reimbursement claims have to be submitted within 45 days of date of DISCHARGE from the hospital24. Disease wise Cappings (Limitations) : -

LAST date of submission: rd23 November 2015, Monday

ADDITIONAL CAPPINGS

i) 50% Co-payment on Pre-existing CANCER

ii) Capping on Dialysis in case of Pre-existing Disease

iii) Limit on claim amount (Capping) for Diseases / Ailments

iv) 10% Co-payment on REMAINING Pre-existing Diseases

v) Deduction of ₹5,000

RENEWAL coverage

Co-payment of 50% on claims due to Cancer related treatment only in case of Pre-existing Disease before Previous year Policy start date

₹35,000 Per Family Per Year

Cataract (Per eye): Bypass Surgery (CABG): ₹250,000 Valve Replacement: ₹200,000Angioplasty (PTCA): ₹175,000Cholecystectomy (Gall bladder removal): ₹40,000Hysterectomy (Removal of Uterus): ₹40,000Appendisectomy (Removal of Appendix): ₹40,000Fistula / Hernia : ₹30,000Angiography: ₹18,000 Anaemia: ₹50,000Knee Replacement (Per Knee): ₹125,000All the above mentioned amount inclusive of implant cost, stent, etc

10% co-payment applicable on pre-existing ailment (eg. Cancer, excluding above ALL capped ailments Dialysis, Bypass etc)

Deduction of ₹5,000 for each & every excluding above ALL capped and Pre-existing claim above ₹50,000ailments

PREVIOUS YEAR coverage

Limit not Applicable

Limit not Applicable

Cataract (Per eye): ₹24,000

No Limit on all other ailments / Diseases

No Co-payment

No Deduction

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1. INDIVIDUAL / FAMILY FLOATER Mediclaim for JIO Members only. 2. AGE LIMIT 0-80 years (Entry Age of Proposer Between 18 to 80 Years). 3. We are happy to announce that the existing ELDERLY MEMBERS covered under the Policy who have already completed 80 years of age, are welcomed to

continue the cover in the Renewal also. 4. INDIVIDUAL POLICY with Sum Insured of ₹ 2 Lacs available only for member BELOW 40 years. 5. Existing members BELOW 40 YEARS covered under Individual Policy of ₹ 2 Lacs CAN ALSO convert their cover from ₹ 2 Lacs to Family Floater of ₹ 5 Lacs or ₹ 10

Lacs and they can also add their family members. 6. Existing members ABOVE 40 YEARS covered under Individual Policy of ₹ 2 Lacs SHOULD convert their cover from ₹ 2 Lacs to ₹ 5 Lacs or ₹ 10 Lacs and they can also

add other family members as per family definition (1+5). 7. FAMILY FLOATER MEDICLAIM Sum insured of ₹ 5 Lacs or ₹10 Lacs only. 8. FAMILY DEFINITION : Proposer + Spouse (Husband / Wife) + 2 Dependent children upto 25 years of age + 2 Parents OR In-Laws (Any 1 set of Parents to be covered.

Combination not allowed) means Maximum 6 members allowed in one family floater (1+5). 9. If proposer has covered his/her family in family floater Policy and apart from the above mentioned family of 6 members, he / she have 3rd or 4th CHILD or any other

REMAINING family member below 40 years; he/she can be enrolled as a proposer for another Individual Policy even if his/her age is LESS THAN 18 years. 10. Any person can't be covered more than once under whole group in JIO Policy. If declared more than once, benefit would be payable under one Sum Insured only 11. ROOM RENT & ICU CHARGES limitation Per Day (Inclusive of Nursing charges) :

**If insured is admitted in a higher category, then insured will bear difference of all medical expenses as in final hospital bill in same proportion. All other charges to be settled as per room eligibility except pharmacy/medicine charges

12. PRE-EXISTING DISEASES are covered from Day One. 13. NO MEDICAL CHECK-UP required. 14. DAY CARE PROCEDURES Covered as per Insurance company norms. 15. All Internal congenital Diseases are covered. 16. TERRORISM Covered from Day One. 17. 30 Days Pre Hospitalisation & 60 Days Post Hospitalisation expenses covered. 18. Maternity Benefit covered with limit of Rs. 30,000 for NORMAL Delivery and Rs. 35,000 for CAESARIAN Delivery. 19. NEW BORN BABY covered from Day 1 subject to intimation within 20 days (Only Reimbursement cases). 20. Hospitalization expenses for ORGAN TRANSPLANT (excluding cost of organ) : The Insurance Company will pay expenses incurred on the donor and the insured

recipient up to the sum insured of the insured recipient. 21. DENTAL TREATMENT covered if due to accident only and requiring 24 hours Hospitalisation. 22. MID-TERM ADDITIONS allowed only for natural additions subject to intimation received within 20 days of marriage or birth (for newly married SPOUSE & new born

BABY). 23. CLAIM INTIMATION for all reimbursement claims have to be intimated within 7 days of ADMISSION, failure to intimate will lead to rejection of the claim. 24. CLAIM SUBMISSION of documents for reimbursement claims have to be submitted within 45 days of date of DISCHARGE from the hospital. 25. As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption. (Exemption for Payment by Cash not applicable). 26.

“DISCLAIMER”: The above mentioned information is only indicative in nature. For details of coverage and exclusions, please refer to the policy wordings. Insurance is the subject matter of solicitation."Coverage shall commence on a common date and not from the date member has filled /made the payment as this is a Group Mediclaim Policy"

COURIER Forms in a Sealed Envelope at JIO PHASE -1 (RENEWAL) C/O ALLIANCE INSURANCE BROKERS PVT LTD., No. 102, 1st Floor, Rani Villa, 10th Road, JVPD Scheme, Vile Parle (W), Mumbai – 400049

For Queries Please Call on 02266876777 ( from 10am to 6pm )

LAST date of submission: rd23 November 2015, Monday

ADDITIONAL CAPPINGS

i) 50% Co-payment on Pre-existing CANCER

ii) Capping on Dialysis in case of Pre-existing Disease

iii) Limit on claim amount (Capping) for Diseases / Ailments

iv) 10% Co-payment on REMAINING Pre-existing Diseases

v) Deduction of ₹5,000

RENEWAL coverage

Co-payment of 50% on claims due to Cancer related treatment only in case of Pre-existing Disease before Previous year Policy start date

₹35,000 Per Family Per Year

Cataract (Per eye): Bypass Surgery (CABG): ₹250,000 Valve Replacement: ₹200,000Angioplasty (PTCA): ₹175,000Cholecystectomy (Gall bladder removal): ₹40,000Hysterectomy (Removal of Uterus): ₹40,000Appendisectomy (Removal of Appendix): ₹40,000Fistula / Hernia : ₹30,000Angiography: ₹18,000 Anaemia: ₹50,000Knee Replacement (Per Knee): ₹125,000All the above mentioned amount inclusive of implant cost, stent, etc

10% co-payment applicable on pre-existing ailment (eg. Cancer, excluding above ALL capped ailments Dialysis, Bypass etc)

Deduction of ₹5,000 for each & every excluding above ALL capped and Pre-existing claim above ₹50,000ailments

PREVIOUS YEAR coverage

Limit not Applicable

Limit not Applicable

Cataract (Per eye): ₹24,000

No Limit on all other ailments / Diseases

No Co-payment

No Deduction

3. INDIVIDUAL MEDICLAIM POLICY with Sum Insured of Rs. 2 Lacs available only

An Initiative to ensure the health of all Jain Shravak & Shravika's

Inspiration & Blessings – Gurudev Shri Naypadmasagarji MaharajsahebMuni Shri DhyanpadmasagarjiVidushi Sadhvi Shri Maynashreeji

Muni Shri AkshaypadmasagarjiSadhvi Shri Siddhimaynashreeji

&& ¶moJ{Zð> AmMm¶© lr‘X² ~w{Õ-H$s{V©-H¡$bmg-gw~moY-‘Zmoha-H$ë¶mU-nX²‘-A‘¥VgmJa-gw[aídaoä¶mo Z‘… &&

DISCLAIMER : Coverage will start from a common date & not from the date member has made the payment as this is a Group Mediclaim Policy.

COURIER Forms in a Sealed Envelope at..... JIO PHASE - 3 C/O ALLIANCE INSURANCE BROKERS PVT LTD.,

No. 102, 1st Floor, Ranee Villa, 10th Road, JVPD Scheme, Vile Parle (W), Mumbai – 400 049

PHASE-3 MEDICLAIM

Managed By : Jain Doctor's Federation

3.2 Lakhs Shravak Members with their families are already covered under this scheme

I) 50% Co-payment on claims due to Cancer related treatment only in case of Pre existing Disease

ii) Capping on Dialysis in case of Pre-existing Disease ₹ 35,000 Per Family Per Year

iii) Capping on Diseases

iv) 10% Co-payment on REMAINING Pre-existing Diseases excluding above ALL capped diseases (eg. Cancer, Dialysis, Bypass etc)

v) Deduction of Rs. 5,000 for each & every claim above ₹ 50,000 excluding above ALL capped & Pre-existing diseases

Cataract (Per eye) : ₹ 24,000

Bypass Surgery (CABG) : ₹ 2,50,000

Valve Replacement : ₹ 2,00,000

Angioplasty (PTCA) : ₹ 1,75,000

Cholecystectomy (Gall bladder removal) : ₹ 40,000

Hysterectomy (Removal of Uterus) : ₹ 40,000

Appendisectomy (Removal of Appendix) : ₹ 40,000

Fistula / Hernia : ₹ 30,000

Angiography : ₹ 18,000

Anaemia : ₹ 50,000

}Latest Benefits

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&

" " "

1. Mediclaim for JIO Members only2. FAMILY FLOATER MEDICLAIM Sum insured of ₹ 5 Lac & ₹ 10 Lacs only3. FAMILY DEFINITION : Proposer + Spouse ( Husband / Wife ) + 2 Dependent children up to 25 years of age + 2 Parents OR In-Laws ( Any 1 set of Parents to be covered. Combination not allowed ) maximum 6 members with self- mandatory (1+5 )4. INDIVIDUAL POLICY with Sum Insured of ₹ 2 Lacs available only for individuals BELOW 40 years.5. Apart from the above mentioned family of 6 members, if proposer have 3rd or 4th CHILD OR ANY OTHER REMAINING FAMILY MEMBER; he/she can be enrolled as a proposer for an Individual

mediclaim policy with a sum insured of 2 Lac (even if his/her age is less than 18 years but age should be below 40 years) subjected to the proposer have already covered the entire family under the family floater option.

6. AGE LIMIT 0-80 years (Entry Age of Proposer Between 18 to 80 Years) 7. 1st year entry age is up to 80 years and upon renewal they can continue in the policy till LIFETIME

8. PRE-EXISTING DISEASES are covered from Day One • 9. NO MEDICAL CHECK-UP required

10. CASH LESS facility for more then 3200 hospitals

11. All Internal congenital Diseases covered • 12. Domiciliary Hospitalisation Covered up to 20% of Sum Insured13. Maternity Benefit covered with limit of ₹ 30,000 for NORMAL Delivery and ₹ 35,000 for CAESARIAN Delivery with 9 month waiting period .14. NEW BORN BABY covered from Day 1 subject to timely enrollment in JIO Policy (Only Reimbursement cases)15. Hospitalisation AYUSH Treatment (AYURVEDIC / HOMEOPATHIC / UNANI) ₹10,000 Per claim and Max. up to ₹20,000 per family per year

16. Hospitalization arising out of PSYCHIATRIC AILMENTS Covered up to ₹30,000 • 17. Liability for Nasal Sinus Surgeries Covered up to ₹35,000

18. Cyberknife treatment Covered with Co-pay of 50% • 19. Stem Cell Transplantation Covered with Co-pay of 50% 20. Cochlear Implant treatment Covered up to 50% of the Sum Insured21. Knee Replacement Covered with waiting period of 1 year - Limit of ₹1.25 Lacs per knee.22. Hospitalization expenses for ORGAN TRANSPLANT (excluding cost of organ) : The Insurance Company will pay expenses incurred on the donor and the insured recipient up to the sum

insured of the insured recipient23. DENTAL TREATMENT covered if due to accident only and requiring 24 hours hospitalisation24. As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption. (Exemption for Payment by Cash not applicable)25. DAY CARE PROCEDURES Covered as per Insurance company norms26. Hopistalisation due to TERRORISM Covered27. Emergency Ambulance charges up to ₹ 2,500 Per incidence28. 30 Days Pre Hospitalisation & 60 Days Post Hospitalisation expenses covered29. MID-TERM ADDITIONS allowed only for natural additions subject to intimation received within 20 days of marriage or birth (for newly married SPOUSE & new born BABY)30. Any person can’t be covered more than once under whole group in JIO Policy. If declared more than once, benefit would be payable under one Sum Insured only31. ROOM RENT & ICU CHARGES limitation Per Day (Inclusive of Nursing charges) :

32. CLAIM INTIMATION for all reimbursement claims have to be intimated within 7 days of ADMISSION33. CLAIM SUBMISSION of documents for reimbursement claims have to be submitted within 45 days of date of DISCHARGE from the hospital34. Disease wise Cappings : -

An Initiative to ensure the health of all Jain Shravak & Shravika's

Inspiration & Blessings – Gurudev Shri Naypadmasagarji MaharajsahebMuni Shri DhyanpadmasagarjiVidushi Sadhvi Shri Maynashreeji

Muni Shri AkshaypadmasagarjiSadhvi Shri Siddhimaynashreeji

&& ¶moJ{Zð> AmMm¶© lr‘X² ~w{Õ-H$s{V©-H¡$bmg-gw~moY-‘Zmoha-H$ë¶mU-nX²‘-A‘¥VgmJa-gw[aídaoä¶mo Z‘… &&

“DISCLAIMER”: The above mentioned information is only indicative in nature. For detail Policy Coverages, Terms & Condition, Exclusion and FAQ, please visit our website www.jio.net.in Insurance is the subject matter of solicitation."Coverage shall commence on a common date and not from the date member has filled /made the payment as this is a Group Mediclaim Policy"

COURIER Forms in a Sealed Envelope at..... JIO PHASE - 3 C/O ALLIANCE INSURANCE BROKERS PVT LTD.,No. 102, 1st Floor, Ranee Villa, 10th Road, JVPD Scheme, Vile Parle (W), Mumbai – 400 049

For Queries Please Call on 02266876777 (From 10am to 6pm - Monday to Saturday)

PHASE-3 MEDICLAIM

Managed By : Jain Doctor's Federation

3.2 Lakhs Shravak Members with their families are already covered under this scheme

I) 50% Co-payment on Pre-existing CANCER

ii) Capping on Dialysis in case of Pre-existing Disease

iii) Limit on claim amount (Capping) for Diseases / Ailments

iv) 10% Co-payment on REMAINING Pre-existing Diseases

v) Deduction of Rs. 5,000

Co-payment of 50% on claims due to Cancer related treatment only in case of Pre existing Disease

₹ 35,000 Per Family Per Year

Cataract (Per eye) : ₹ 24,000Bypass Surgery (CABG) : ₹ 2,50,000 Valve Replacement : ₹ 2,00,000Angioplasty (PTCA) : ₹ 1,75,000Cholecystectomy (Gall bladder removal) : ₹ 40,000Hysterectomy (Removal of Uterus) : ₹ 40,000Appendisectomy (Removal of Appendix) : ₹ 40,000Fistula / Hernia : ₹ 30,000Angiography : ₹ 18,000 Anaemia : ₹ 50,000Knee Replacement (Per Knee) : ₹ 1,25,000All the above mentioned amount inclusive of implant cost, stent, etc.

10% co-payment applicable on pre-existing ailment excluding above ALL capped ailments(eg. Cancer, Dialysis, Bypass etc)

Deduction of ₹ 5,000 for each & every claim above ₹ 50,000 excluding above ALL capped and Pre-existing ailments

}New Additions

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&

SUM INSURED LIMIT per day

₹ 200,000 & ₹ 500,000 (For both policies) ₹ 2,500 for Regular Room & ₹ 4,000 for ICU Hospitalisation

₹ 10,00,000 ₹ 3,500 for Regular Room & ₹ 4,000 for ICU Hospitalisation****If insured is admitted in a higher category, then insured will bear difference of all medical expenses as in final hospital bill in same proportion.

All other charges to be settled as per room eligibility except pharmacy/medicine charges

" " "

SUM INSURED LIMIT PER DAY

₹ 200,000 & ₹ 500,000 (For both policies) ₹ 2,500 for Regular Room & ₹ 4,000 for ICU

₹ 10,00,000 ₹ 3,500 for Regular Room & ₹ 4,000 for ICU

****If insured is admitted in a higher category, then insured will bear difference of all medical expenses as in final hospital bill in same proportion. All other charges to be settled as per room eligibility except pharmacy/medicine charges.

For all Policy details &for ONLINE REGISTRATION

please visit

www.jio.net.in

(inclusive of implant cost, stent, etc.)

For Queries Please Call on 022 6687 6777

10am to 6pm • MON to SAT

+ Parents OR In-Laws (any 1 set of PARENTS TO BE COVERED (combination not allowed))

OR5

6 Mother in Law

Father in Law D D M M Y Y Y Y

D D M M Y Y Y Y

5

6

FATHER

MOTHER

D D M M Y Y Y Y

D D M M Y Y Y Y

In case of Emergency Alternate Contact Number +91

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# All the fields are compulsory

Declaration : I have read and understood all the terms & conditions related to the Phase-3 MediclaimScheme I abide to follow them and accept all the changes / modifications / amendments / etc. and the rules and conditions of the scheme. I also hereby confirm that all the details mentioned by me arecorrect and to the best of my knowledge. In all matters the decision of JIO will be final.For more details please visit website http://www.jio.net.in

Signature of Proposer

** JIO has the Right to TERMINATE (Reject) this application, if any details provided are inappropriate.

Phase - 3 MEDICLAIM* Date: 2 0 1 5D D M M

2 Dependent Children upto 25 years of age 3

4

CHILD (1)

CHILD (2)

D D M M Y Y Y Y

D D M M Y Y Y Y

*** If family members also have their personal JIO ID (16 digit), then please mention below

JIO ID No. (If available) NameSr. No.

2

Relation

Spouse

M/F DOB Age

D D M M Y Y Y Y

Full Name of ProposerFIRST NAME MIDDLE NAME LAST NAME

PERSONAL ACCIDENT POLICY

FOR PERSONAL ACCIDENT POLICYNominee Name:

Relation:

Gender: PROPOSER'S SIGNATUREM / F

Sum Insured of Personal Accident policy is ₹ 10 Lacs, ₹ 5 Lacs or ₹ 2 Lacs for Proposer only as per Mediclaim Policy Sum Insured

INSURANCE FACILITATOR• Demand Draft / Pay Order should be made in favor of “JAIN INTERNATIONAL ORGANISATION A/c Shravak Arogyam “Payable AT PAR or AT MUMBAI.

• Cash / Cheque will not be accepted • Premium can also be paid ONLINE, please visit our website www.jio.net.in

Address

Area

( ) ( )Phone No.STD CodePremium (Select any one scheme)

14.5% Service Tax

Included

Bank Name__________________________________________________________________ Branch Name ______________________________________

Demand Draft / Pay Order no.: Amount :

REGISTRATION FORM Receipt No.:

₹ 10 Lacs (Family Floater) - ₹ 28,565/-

₹ 5 Lacs (Family Floater) - ₹ 17,060/-

₹ 2 Lacs (Individual cover) - ₹ 3,320/-

* * ₹ 2 Lacs Individual cover option is only available for the individuals below the age of 40 years.

SelectANY ONEScheme

Premium [Including 14.5% Service Tax]

JIO ID of the Primary Member is compulsory ( for family member it is not compulsory ) **If not a member then please send the JIO membership form along with this form

Proposer's JIO ID (16 digit) D D M M Y Y Y YDate of BirthGender M/F Age

Mobile +91

In case of Emergency Alternate Contact +91

Date of Birth : D D M M Y Y Y Y

" " "

Last Date of Submission23rd DECEMBER 2015

Receipt No. ...................................................................................... DD / Pay Order No. ............................................................................................................ Rupees ₹

Received at .............................................................................................................................................................................................................................. City ..................................................................

Authorised Signatory 2 0 1 5D D M MDateReceived by

Jain International Organisation - JIO's other SUPPORTING & CONNECTED Associations:All Shravak-Shravika Members of all four Sects, Active Volunteers of Jain Sangh & Samaj, from All over India Mahila Mandal & Yuvak Mandal,

Yuvak Mahasangh, Jain CA Federation (JCAF), Jain Advocate Federation (JAF), Jain International Women Organisatoion (JIWO), Jain International Youth Organisation (JIYO)JIO’s Media / Educationist / Technocrats / Business organisations and many other Jain Organisations in field of education / business / Profession / social services etc.

D D M M Y Y Y YDated

* If you still haven't received the 16 digit JIO ID then also send the JIO membership form along with this form