MEDICAL PRACTITIONER'S REPORT

For insured person aged 60 years and above, ECG, Urine strip test and Blood Sugar test reports, (Fasting
and Postprandial) to be enclosed and the following questionnaire to be completed by a Medical Practitioner
registered with Indian Medical Association.  These tests should have been done within a period of 60 days
prior to the date of commencement of the policy.

Name of the Insured Person                                                                                                           

Name of the Card Member                                                                                                            

CITIBANK Credit Card Number                                                                                                 

Based on my medical examination of Mr/Ms.                                                                                                         

aged                  years on                                     and the medical reports (ECG, Blood Sugar/Urine Strip Test)

relating to  him/her, I certify as follows:

1.  ECG REPORT :

        Does the attached ECG in your professional opinion show any abnormalities.          YES /  NO

        If YES, please describe
        Does the abnormality represent any Heart Disease                                                   YES / NO

2.  BLOOD SUGAR/URINE STRIP TEST REPORT :

        Does the attached Blood Sugar/Urine test report show any abnormality                    YES / NO

        Does the abnormality in your professional opinion represent any Diabetes Mellitus    YES / NO

3.  OBSERVATIONS FROM GENERAL / SYSTEMIC EXAMINATION

        Does He / She suffer from any physical and / or mental disease or infirmity
        or medical compliants                                                                                              YES / NO

        If YES, please describe with details

SIGNATURE OF MEDICAL PRACTITIONER                  SIGNATURE OF INSURED PERSON

Date   :                                                                                        Date   :   

Name :                                                                                        Name :

Qualifications :

Regn. No.     :

Address        :


Telephone     :

(Proposals accepted based on these reports does not prejudice the rights of the Insurer to disclaim liability in
respect of any pre-existing disease whether disclosed or not)