We / I giving consent to Assistance to take care of Elderly Members as mentioned/ filled up in this form in respect of their welfare during normal health condition as well as facilitate medical treatment, in general, / during the emergency (for hospitalization as directed by a competent physician / your suggestion/consent as applicable). The cost of all Medical Treatment at Home / Hospital Any other Expenses other than Complementary Services as mentioned in your Leaflet be Bourne by us. We will maintain / provide adequate Fund for any kind of Treatment at Home / Hospital. We understand that ASSISTANCE is no way responsible for the outcome of Clinical Treatment / Procedure provided to Elderly Members as directed by Physicians at Hospital / Home.

I /We agree to accept the service as per the terms and conditions of Assistance to be enclosed separately.