Proposalform
Proposalform
Proposalform
ALL UNIT LINKED POLICIES ARE DIFFERENT FROM TRADITIONAL INSURANCE POLICIES AND ARE SUBJECT TO DIFFERENT RISK FACTORS.
IN UNIT LINKED POLICY THE INVESTMENT RISK IN YOUR CHOSEN INVESTMENT PORTFOLIO IS BORNE BY YOU Photograph of life to be assured*
to be signed across by the life to
be assured
* Not mandatory if life to be
assured is different from the
1) The entire form is to be filled in black ink only by the policyholder. Use CAPITAL letters for information required in boxes with a space between Proposer except if Life to be
assured is minor
words. 2) Any cancellation / alteration is to be signed by the proposed policyholder or life to be assured as appropriate. 3) All information provided here
shall be relied on and should be accurate, complete and true in all respects for processing the proposal quickly. In case you have any doubt whether the
particular information is material or not, please disclose the information. 4) Please attach an extra sheet, wherever additional information is to be given.
Country of Residence:
Country of Workspace:
Permanent Country:
9. If you are our existing life NA
assured, assignee, nominee,
proposers kindly enter Policy
No./Customer ID:
10. Correspondence 16/12 B Civil lines Kanpur, , Kanpur, Uttar Pradesh-208001 India
Address:
11. Permanent Address (If 16/12 B Civil lines Kanpur, , Kanpur, Uttar Pradesh-208001 India
different from
correspondence address)/
Overseas residential
address for NRI / PIO / OCI :
12. Mobile: 919335506769
Telephone No(R):
Telephone No(O):
EmailId: [email protected]
Email ID if provided, will be
considered as preferred mode of
communication
Salaries Business House Property Capital Gains Investments Agriculture Others Total
0% 100% 0% 0% 0% 0% 0% 100%
5. Relationship with
Primary Life Assured:
6. Date of Birth (DD/MM/ 04/07/1956
YYYY) :
7. Gender(M/F/Tg): Male
8. Marital Status: Married
9. Nationality: Indian
10. Education: Graduation
11. Resident status: Resident Indian
If you are NRI/PIO/OCI, Please
attach appropriate Questionnaire.
Country of Residence:
Country of Workplace: India
Permanent Country:
12. Mobile: 919335506769
Telephone No(R):
Telephone No(O):
EmailId: [email protected]
Email ID if provided, will be
considered as preferred mode of
communication
Preferred language of
communication:
13. Present Occupation: Self employed/ Business
14. Gross Yearly Income 4,00,000
(INR):
15. Workplace Name and Kwality Salon, 24 1 Phool Bagh Mall road Kanpur, Kanpur, India
Address:
16. Industry Type (cement, Beauty & Cosmetics
baking, etc.):
17. Exact Nature of work Managerial
(clerical, mechanical,
supervisory job, etc.):
18. Nature of Occupation Owner
(architect, etc.):
19. Income Proof : Identity Proof :
Address Proof : Age Proof (Life Assured):
PAN* :
20. PAN Photocopy enclosed
(*Submit Form 60 if PAN is not available)
:
21. Do you want policy in E insurance account number:
Demat Format?If a policy is
requested in demat form, it will not be
given in physical form and vise versa.
22. Do you have any history of conviction / acquittal under any criminal proceedings in
India or abroad? No
23. If Life to Assured is a student/housewife, please provide insurance details regarding
parents/husband/siblings.
(Please attach a separate sheet for multiple policies if required.)
Total Sum Assured of all Policy No. and Name of Husband's / Parent's
inforce life insurance Company Occupation / Income
policies
1. Have you submitted any simultaneous applications for life insurance at any of our offices or to another life insurance company, which is still pending OR are No
you likely to revive lapsed policies?
Name of the Sum Assured Types of Purpose of Proposed To be revived
company/ies payable on products cover
death (INR)
2. Please provide the details of any existing insurance cover of premium paying and/or paid up policies accepted at standard rate excluding group term insurance Yes
plan taken by your employer. (Also provide the details of any such proposals on your life / application for instatement ever accepted with extra premium, accepted
on other special terms, postponed, declined or withdrawn by self)
Policy / Company Year of Basic Sum Annual Base Medical Inforce /
Proposal Name Issue / Assured Premium Plan / Policy Lapsed*
No. Application (INR) (INR) Rider
Decision
3. Name, Address and Contact number of your family doctor: Alok Nigam
5a. Product Details: Product Name Cover type(Self/ Plan Option Policy Term(in Premium Sum Assured Extra -Life Modal
PPH/HUF/MWPA/ years) Payment(in years) (in INR) Sum Assured Premium
Business) (in INR) (Exclusive of taxes
and levies as
applicable)
8. Top-up Premium (INR): NIL Top-up Sum Assured (INR): NIL Total Premium (INR): 8,000
(Inclusive of taxes and levies as applicable)
10. For unit linked plans, kindly indicate % of allocation in below mentioned funds as applicable (please check the fund for the product applied)
Equity Plus Blue Chip Diversified Opportunities Balanced Fund Income Fund Bond Fund Conservative Discovery Equity Total(%)
Fund Fund Equity Fund Fund Fund Fund Advantage
Fund
0 25 0 0 50 25 0 0 0 0 100
Payout Mode
Selected mode would be used by the company to make payout(s) to the Proposer. Payout would be in accordance and subject to the terms and conditions of the policy.
Declaration: 1. In case of non credit to my bank account with/without assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete / incorrect information, I would not hold HDFC Life Insurance Co. Ltd
responsible. 2. In case of NRI/NRE account, cheque will be issued.
Signature of Proposer
Signature of Witness Signature/Thumb impression of life to be assured. Signature/Thumb impression of proposed policyholder
Signature should match with signature on ECS/SI (Only if different from life to be assured) Signature should
mandate match with signature on ECS/SI mandate
Occupation_____________________
Date: Place: Date: Place:
Mobile: Mobile:
Declaration of good health for spouse (to be filled only for Elite option of Smart Woman Plan)
Declaration (If signed in Vernacular language / If you have affixed a Thumb impression above)
Declaration to be made by a 3rd person where: The life to be assured/proposed policyholder has affixed his/her thumb impression; OR the life to be assured/proposed
policyholder has signed in vernacular; OR the life to be assured/proposed policyholder has not filled the application OR/AND The spouse of the life to be assured/
proposed policyholder has affixed his/her thumb impression or signed in vernacular the Declaration of Good Health applicable under Elite Option of Smart Woman Plan.
I hereby declare that I have explained the contents of this application form to the life to be assured / proposed policyholder in ________________________language and have
truthfully recorded the answers provided to me. I further declare that the life to be assured/proposed policyholder has signed/affixed his/ her thumb impression in my presence.
____________________________________________________________________________________________________ ___________________________________
Name and address of Declarant Signature
I hereby declare that the content of the form and document has been fully explained to me and I have fully understood the significance of the proposed contract.
_____________________________________________________________________ ______________________________________
Signature/Thumb impression of life to be assured/proposed policyholder Signature/Thumb impression of Witness
Section 41 - Prohibition of rebates: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take 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.
Section 45 - 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, i.e., from the date of
issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later. 2. A policy of life insurance may be
called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud: Provided that 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. 3.Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life
insurance policy on the ground of fraud if the insured can prove that the mis-statement of or suppression of a 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 of or suppression of a material fact are within the knowledge of the insurer: Provided that in case of fraud,
the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive. 4.A policy of life insurance may be called in question at any time within three years from the date
of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, 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: Provided that 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 to repudiate the policy of life insurance is based: Provided further that in case of repudiation of the policy on the ground of misstatement
or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal representatives
or nominees or assignees of the insured within a period of ninety days from the date of such repudiation. 5. 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.