Customer's Declaration: Assessment of Suitability and Appropriateness For Sale of Third Party Products
Customer's Declaration: Assessment of Suitability and Appropriateness For Sale of Third Party Products
Customer's Declaration: Assessment of Suitability and Appropriateness For Sale of Third Party Products
Ltd
Corporate Office: 'Natraj', M.V.Road and Western Express Highway Junction, Andheri (East), Mumbai - 400069
IRDAI Registration No. 111 | Website: www.sbilife.co.in | Email: [email protected] | CIN: L99999MH2000PLC129113
Toll Free: 1800 267 9090 (Between 9.00 am & 9.00 pm)
Customer’s Declaration:
Assessment of Suitability and Appropriateness for Sale of Third Party Products
Customer's Declaration:
I express my willingness to buy the SBI Life -Smart Swadhan Plus and declare that the above information are
provided voluntarily and confirm that the personal financial details submitted to the Bank are true & correct to the
best of my knowledge.
(Signature of the customer) This document is eSigned by Proposer.
Name: Mr. PANCHU SWAIN
Account No.: 331029295944
Mobile No.: 9178878144
Email ID:
Date: 7-10-2020
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SBI Life Insurance Co. Ltd
Registered & Corporate Office: 'Natraj', M.V.Road and Western Express Highway Junction, Andheri (East), Mumbai - 400069
IRDAI Registration No. 111 | Website: www.sbilife.co.in | Email: [email protected] | CIN: L99999MH2000PLC129113
Toll Free: 1800 267 9090 (Between 9.00 am & 9.00 pm)
Introduction
The main objective of the illustration is that the client is able to appreciate the features of the product and the flow of benefits in different
circumstances with some level of quantification. For further information on the product and its benefits, please refer to the sales brochure and/or
policy document.
Name of the Prospect/Policyholder Mr. PANCHU SWAIN Name of the Life Assured Mr. PANCHU SWAIN
This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.
Policy Details
Mode / Frequency of Premium Yearly Rate of Applicable Taxes 4.5% in the 1st policy year and
Payment 2.25% from 2nd policy year
onwards
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Premium Summary
Please Note
1. The premiums can be also paid by giving standing instruction to your bank or you can pay through your credit card.
2. Applicable Taxes (including surcharge/cess etc), at the rate notified by the Central Government/ State Government / Union Territories of India from
time to time and as per the provisions of the prevalent tax laws will be payable on premium as per the product features.
1 15,855 0 0 0 7,00,000 0 0
Notes
1. Annualized premium shall be the premium amount payable in a year chosen by the policyholder, excluding the taxes, underwriting extra premiums
and loading for modal premiums, if any / Single premium shall be the premium amount payable in lumpsum at inception of the policy as chosen by
the policyholder, excluding the taxes and underwriting extra premiums, if any. Refer sales literature for explanation of terms used in this illustration.
2. All Benefit amount are derived on the assumption that the policies are 'in-force'
Important:
You may receive a welcome call from our representative to confirm your proposal details like Date of Birth,Nominee Name,Address,Email Id,Sum
Assured,Premium amount,Premium Payment Term etc.
You may have to undergo Medical tests based on our underwriting requirements.
I, Mr. PANCHU SWAIN having received the information with respect to the above, have understood the above statement before entering
into the contract.
Place :KHORDA
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Date :7-10-2020
I, RENU SAGAR have explained the premiums and benefits under the product fully to the prospect/policyholder.
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Proposal Number 1ZYC089653
Foreign Account Tax Compliance Act (FATCA)/ Common Reporting Standard(CRS)/ C-KYC
Declaration Form – For Individual only (including sole proprietors)
(Please consult your professional tax advisor for further guidance on your tax residency, if required)
Registered & Corporate Office: SBI Life Insurance Co. Ltd, Natraj, M.V. Road & Western Express Highway
Junction, Andheri (East), Mumbai - 400 069.IRDAI Registration no. 111.
website: www.sbilife.co.in | Email: [email protected] | CIN: L99999MH2000PLC129113 | Toll Free: 1800 267 9090
(Between 9:00 AM & 9:00 PM).Trade logo displayed above belongs to State Bank of India and is used by SBI Life
under license.
C-KYC number NA
GSTIN
1 NA NA NA
2 NA NA NA
#To also include United States of America(USA), where the individual is a citizen/ green card holder of USA. %In case such number is not available,Kindly provide an explanation and attach it
to this form.
SI No Residence address/(es) for Tax Address Type Country code Telephone/ Mobile No
purposes
1 NA NA NA NA
2 NA NA NA NA
FATCA/CRS Instructions
In case Proposer/Accountholder has the following Indicia pertaining to a foreign country and yet declares self to be non-
tax resident in the respective country,Proposer/Accountholder to provide relevant Curing Documents as mentioned below:
FATCA/ CRS Indicia observed (ticked) Documentation required for Cure of FATCA/ CRS indicia/n(If Proposer/Accountholder
does not agree to be Specified USA person/ reportable person status)
a) United States of America (“USA”) place of birth 1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA;
2. Non-USA passport or any non-USA government issued document evidencing nationality or
citizenship (refer list below); AND
3. Any one of the following documents:
a. Certified Copy of “Certificate of Loss of Nationality or
b. Reasonable explanation of why the Proposer/Accountholder does not have such a certificate
despite renouncing USA citizenship; or Reason the Proposer/Accountholder did not obtain USA
citizenship at birth
b) Residence/mailing address in a country other than India 1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes ofUSA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)
c) Telephone number in a country other than India (and no telephone number in India provided) 1. Self-certification ( as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)
d) Standing instructions to transfer funds to an account maintained in a country other than India 1. Self-certification ( as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)
List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body**
2. Valid identification issued by an authorized government body**(e.g.Passport,National Identity card, etc.)
**Government/ agency thereof or a municipality of the country or territory inwhich the Proposer/Accountholder claims to
be a resident.
I, Mr. PANCHU SWAIN, hereby give my voluntary consent to SBI Life Insurance Company Limited (SBI Life) and
authorise the Company to obtain necessary details like Name, DOB, Address, Mobile Number, Email, Photograph through
the copy of Aadhaar card / QR code available on my Aadhaar card / XML File shared using the offline verification process
of UIDAI.
I understand and agree that this information will be exclusively used by SBI Life only for the KYC purpose and for all
service aspects related to my policy/ies, wherever KYC requirements have to be complied with, right from issue of policies
after acceptance of risk under my proposals for life insurance, various payments that may have to be made under the
policies, various contingencies where the KYC information is mandatory, till the contract is terminated.
I have duly been made aware that I can also use alternative KYC documents like Passport, Voter's ID Card, Driving
licence, NREGA job card, letter from National Population Register, in lieu of Aadhaar for the purpose of completing my
KYC formalities. I understand and agree that the details so obtained shall be stored with SBI Life and be shared solely for
the purpose of issuing insurance policy to me and for servicing them. I will not hold SBI Life or any of its authorized
officials responsible in case of any incorrect information provided by me. I further authorize SBI Life that it may use my
mobile number for sending SMS alerts to me regarding various servicing and other matters related to my policy/ies.
Place KHORDA
Date 07-10-2020
4
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Proposal Number 1ZYC089653
2. Are You an Existing SBI Life Customer?(If Yes, provide Customer ID/ Policy No) No
3. Whether Proposal is Under : (If any option is selected, please submit relevant NA
Questionnaire/annexure/supporting documents along with the Proposal form as applicable)
5.Do you want to assign this policy on Issuance? (If yes, please submit relevant No
documents/annexure with the Proposal form)
Middle Name NA
CPF.ver.06-01-20 PF ENG 1
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Proposal Number 1ZYC089653
Domicile Rural
C-KYC number NA
PAN EURPS4953K
7 a. Qualification Graduate
7 b. Age Proof Aadhar card with complete DOB 7 c. Identity Proof Aadhar Card
7 d. Address
GSTIN of policyholder NA
Permanent Address (For NRI, Indian Permanent address to be provided) C/O, JENAPUR Banki Banki Nuagan CUTTACK-CUTTACK,
754008, ORISSA, India
7 e. Occupation Details
Occupation Service
Designation NA
For Defence personnel- Are you currently engaged or trained for future NA
involvement in any of the following?
Force Name NA
7 f. Are you exposed to any special hazard No If Yes, please provide details NA
associated with your occupation(e.g chemical
factory, mines, explosives, corrosives,
combative duties, oil exploration, high sea
voyage etc.) which may render you susceptible
to injuries or illnesses?
CPF.ver.06-01-20 PF ENG 2
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Proposal Number 1ZYC089653
Has any FIR or Criminal complaint ever been No If Yes,please provide details NA
registered or lodged against you?
Relationship with Proposer Life Assured is same as Proposer Age Proof Aadhar card with complete DOB
Qualification Graduate
Nationality Indian
Occupation Service
In case of more than one nominee please attach an extra sheet & percentage of entitlement should total to 100%
Name NA
II. a) In the last 5 years, have you No If yes, please give details(full NA
Undergone hospitalization for 3 or details, of the illness and the
more days treatment ie conditions, dates,
duration, results, and medication
CPF.ver.06-01-20 PF ENG 3
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Proposal Number 1ZYC089653
II. b) In the last 5 years, have you No If yes, please give details(full NA
Undertaken any medical treatment details, of the illness and the
or required regular monitoring for treatment ie conditions, dates,
more than 14 consecutive days on duration, results, and medication
account of any ailment/accident or taken or being taken)
injury
V) Have you ever had symptoms of, been treated for, been advised to receive treatment or have undergone any investigations/hospitalisation for any of
the following
If any of the above questions is ticked 'Yes' then provide details in the below table. Also provide all related reports
Name of the disease/ disability/ deformity/ Date of Diagnosis Since when Currently under treatment / Recovered Date of hospitalisation/surgery done or if
procedure planned
NA NA NA NA
VII. a) Do you consume any of the following? if yes please give details
CPF.ver.06-01-20 PF ENG 4
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Proposal Number 1ZYC089653
Tobacco (cigs,cigar,gutkha,etc) No NA NA
Alcohol No NA NA
Any Narcotics No NA NA
VII. b) If you have quit any of the above, in the last 1 year, kindly provide details NA
VIII. Are any of your family members (include parents, brothers, sisters, spouse and No
children) suffering from/have suffered from/have died of heart disease, high blood
pressure, diabetes, stroke, cancer, kidney disease or any other hereditary/familial
disorder, before 55 years of age? If yes, please share details in the table below
Particulars,including date of diagnosis.if not
Relation Alive/Not Alive Present Age/Age at Death Nature of Disorder*** (Have any alive,specify cause of death (Have any of your
of your parents, brothers or parents, brothers or sisters died or suffered from
any of the diseases / disorders specified below? ***)
sisters died or suffered from any
of the diseases / disorders
specified below? ***)
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
*** Heart disease, hypertension, high blood pressure, Diabetes,Stroke,Cancer, Kidney disease , any hereditary disease, if any other disease,pls. specify.
2) Have you ever suffered from or have No If Yes, (please share details) NA
undergone any investigations or treatment for
any gynacological problems related to cervix,
uterus, ovaries, breast, breast lump/cyst etc or
undergone surgical procedure like
hysterectomy?
Name of Insurance Co. Policy No. Yearly Premium(Rs) Sum Assured(Rs) Policy status
NA NA NA NA NA
Plan/Cover Options NA
CPF.ver.06-01-20 PF ENG 5
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Proposal Number 1ZYC089653
13 b. Plan/Cover Details
Plan/Rider/option/Benefit Policy Term(Yrs) Premium Payment SAMF Sum Assured(Rs) Premium Payable(Rs)
Term(Yrs)
Backdating Interest 0
14.BackDating(Not available for ULIPs , only available for specific products, upto a date within the same financial year in which the policy has
been taken)
Do you wish to backdate the policy ? NA If Yes, provide the Backdating Date NA
^Please note that SBI Life branches and its sales team are not authorised to collect from its customers
17. Do you have any other individual life insurance policy or have applied for one No
Please submit any one of the below listed Documents for direct credit of Copy of Bank Statement
any refunds/payouts if any, to this account.
I declare that the information given above is true and correct. I shall not hold SBI Life responsible for non-credit/nonpayment of payments due or
refund, if any, due to any reason including but not limited to incorrect/incomplete information.I hereby authorise SBI Life to directly credit any
payment/refund,if any ,to the above mentioned account.
CPF.ver.06-01-20 PF ENG 6
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Proposal Number 1ZYC089653
19. e-Insurance A/C details(As per IRDAI e-Commerece Regulations,eInsurance Account is mandatory for online proposals)
I want to receive the insurance policy and all the information related to the proposed insurance No
policy through insurance repository
• I hereby declare that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my knowledge. I
understand that the information provided by me will form the basis of the insurance policy.
• I understand that, the PROPOSAL WILL NOT BE CONSIDERED UNTIL THE FULL PREMIUM INCLUDING TAXES, IS PAID BY ME.
• I also understand that I am liable to pay all the Applicable Taxes and/or any other statutory levy/duty/ surcharge, at the rate notified by the State
Government or Central Government of India from time to time, as per the applicable tax laws on premium and/or other charges (if any) as per the product
features.
• I understand and agree that risk cover and other benefits will not commence until a written acceptance of this proposal is issued by the company and
THAT THE BENEFITS UNDER THE POLICY shall be strictly as per the terms and conditions of the policy.
• I agree that the amount held in proposal/policy deposit shall not earn any interest except as may be provided in the relevant regulations.
• I understand and agree that the statements in this proposal constitute warranties. If there is any mis-statement or suppression of material information or
if any untrue statements are contained therein or in case of fraud, the said contract shall be treated as per the provisions of section 45 of the Insurance Act,
1938, as amended from time to time.
• I understand that the insurance contract will be governed by the provisions of all the applicable Statutes, as amended from time to time.
• I undertake to undergo all medical tests as may be required by the Company for the grant of insurance.
• I authorize the company to share the information contained in my proposal and the medical records of the insured/proposer with others for the sole
purpose of underwriting the proposal and/or for the purpose of settlement of claims and with any Governmental and/or Regulatory authority.
• I hereby authorize the Company to provide my details to banks, financial institutions, credit bureaus, insurance repository, third party service providers
that the Company may have tie-ups with and insurance intermediary for this proposal/resulting policy for verification of the details of this proposal and
for servicing my policies or settlement of claims.
• I hereby give my consent to receive any information relating to this proposal/resulting policy from SBI LIFE through SMS/Email/Phone /Letter and
hereby authorize SBI LIFE to send any communication pertaining to my policies through SMS/email/phone/letter . This consent shall hold good even if I
register my number with the National Customer Preference Register (NCPR).
• Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and/or employer
from divulging any knowledge or information about me concerning my health, employment on the grounds of secrecy, I, my heirs, executors,
administrator or any other person or persons having interest of any kind whatsoever in the life insurance cover provided to me, hereby agree that such
authority, having such knowledge or information, shall be at any time at liberty to divulge any such knowledge or information to the Company.
• I declare that I am presently in India and I understand that the insurance contract entered into while not in India, will not be valid..
•I am aware that SBI Life-Smart Swadhan Plus is a Limited premium policy and I am aware that I would need to pay premium for 5 years (Premium
Payment Term).
• I agree that by submitting this application , I will be bound by all the statements/disclosures of material facts made through the electronic process in the
same manner and to the same extent, as if I have signed and submitted the written proposal for insurance to the Company. I accept and agree to affix my
signature (in electronic mode/tablet/mobile) here.
• I agree to the above declaration.
• I hereby authorize SBI Life to consider details furnished in the proposal number specified above and in this declaration for the purpose of Central KYC
Registry and to provide my details to CERSAI in the prescribed format. I further hereby consent to receiving information from CKYC Registry through
SMS/Email or registered mobile number/email address mentioned in the proposal no. specified above.
• I hereby declare that I have reviewed details in the Need Analysis,Benefit Illustration,FATCA and relevant questionaires provided. I have also
thoroughly scrutinized all pages of the proposal form . I declare that the information given above is true and correct.
• I understand and agree that by submitting this application through the tablet/mobile device, I shall be bound by such statements/disclosures of material
facts in the same manner and to the same extent, as if I have signed and submitted the written proposal for insurance to the company.
Signature of the Proposer
This document is eSigned by Mr. PANCHU
SWAIN
CPF.ver.06-01-20 PF ENG 7
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Proposal Number 1ZYC089653
21. DECLARATION WHEN THE PROPOSAL FORM IS FILLED BY A PERSON OTHER THAN THE PROPOSER/ VERNACULAR
LANGUAGE/PROPOSER IS ILLITERATE
I hereby declare that I have read out and explained the contents of this proposal form and all other documents incidental to availing the insurance
policy from SBI Life Insurance Company Ltd. to the Proposer and that he/she declared that he/she has understood the same completely.
I hereby declare that I have fully explained to the Proposer the answers to the questions that form the basis of the contract of insurance and I also
explained to the Proposer that if there is any mis-statement or suppression of material information or if any untrue statements are contained therein or
in case of fraud, the said contract shall be treated as per the provisions of Section 45 of the Insurance Act 1938 as amended from time to time.
I hereby declare that I have explained the contents of this form to the Proposer in oriya Language.
I also declare that I have truly and correctly recorded the answers given by the Proposer and that the proposer has affixed his/her thumb impression on
the Proposal form in my presence, after fully understanding the contents thereof.
Signature of Witness
I hereby state that the contents of the form and documents have been fully explained to me in the language I understand and that I have fully
understood the significance of the proposed contract.
Prohibition of Rebates : Section 41 of the Insurance Act, 1938, as amended from time to time,states
1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium
shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in
accordance with the published prospectuses or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
Non-Disclosure : Extract of Section 45 of the Insurance Act 1938, as amended from time to time,states
1. No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy. A policy of
life insurance may be called in question at anytime within three years from the date of the policy, on the ground of fraud or on the ground that any
statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document on the
basis of which the policy was issued or revived or rider issued. The insurer shall have to communicate in writing to the insured or the legal representatives
or nominees or assignees of the insured, the grounds and materials on which such decision is based.
2. No insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement or suppression of material fact
was true to the best of his knowledge and belief or that there was no deliberate intention to suppress the fact or that such mis-statement or suppression are
within the knowledge of the insurer. In case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
3. In case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on the grounds of fraud, the premiums
collected on the policy till the date of repudiation shall be paid.
4. Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be
called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the
proposal.
For complete details of the section and the definition of 'date of policy', please refer Section 45 of the Insurance Act 1938, as amended from time to time.
CPF.ver.06-01-20 PF ENG 8
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