HDFC LIFE GROUP SURAKSHA (Micro-Insurance Product)

A Non-Linked, Non-Participating Group Term Micro Life Insurance Product

MASTER PROPOSAL FORM

To be completed by an authorized official of the Company/Group

a) Name of the Company/Group:
1.
b) PAN card
<attach a copy of PAN card>

a) Address of the Registered Office of the

2. Company/Group:
b) Address of the Head Office:
3. Name and title of the authorized official:
HDFC LIFE GROUP SURAKSHA (Micro-Insurance
4. Name of the Scheme:
Product) (UIN 101N135V02)
Provisional date of commencement of the
5. <DD/MM/YY>:
Scheme
a) Minimum age for membership in this Scheme
<<14 years last birthday >>
as on date of commencement of membership
<<Single Premium : 69 years last birthday
6. b) Maximum age for membership in this Scheme
Limited Premium: 60 years last birthday
as on date of commencement of membership
Regular Premium: 68 years last birthday >>
c) Maximum age at maturity under this scheme 70 years last birthday
7. Premium Deposit Rs. < ------------> in advance
8. Premiums Payable by Members Company / Group
8. Premium Payment Option <Single Pay / Limited Pay / Regular Pay>
9. Premium Frequency <Monthly/ Quarterly / Half Yearly / Yearly / Single>
Other Conditions of eligibility for Membership of
10
Scheme (subject to approval)
<XXX>
No. of persons who wish to avail of the benefits
11. List annexed with all details as required by HDFC Life
under the Scheme:
Insurance Company Limited

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DECLARATION

We agree and confirm that the Policy to be issued under the HDFC Life Group Suraksha (Micro-Insurance Product) by HDFC
Life Insurance Company Limited (the “Insurer”) in our name will be held by us for the benefit of the Insured Members.

We declare that the information provided in this Master Proposal Form is both true and accurate to the best of our knowledge
and is based on the information, provided to us by our eligible members, under Membership Information Forms duly completed
and signed by each of them and forwarded to us.

All the relevant information as required and specified by the Insurer has been compiled by us and furnished to the Insurer and
that the same is true to the best of our knowledge and belief.

We understand and agree that fraud, misrepresentation and forfeiture would be dealt with in accordance with provisions of
Section 45 of the Insurance Act 1938 as amended from time to time. Simplified version of the provisions of Section 45 is
provided below.

We undertake to supply such information as the Insurer may from time to time reasonably require determining the extent of its
liability and the amount of Premium payable under this HDFC Life Group Suraksha (Micro-Insurance Product) Plan.

We agree that the statements and declarations in this Master Proposal Form and those contained in the individual Membership
Information Forms shall be the basis of the contract of insurance between ourselves and the Insurer.

We also agree that the insurances proposed under the Scheme shall not be binding on the Insurer until they are accepted by the
Insurer in writing and the amounts of Premium due there under shall have been duly paid by us in a lump sum on behalf of the
Insured Members covered under the Scheme along with the member information in the format specified by the Insurer.

We agree that the Master Policy to be issued consequent upon this Master Proposal Form shall be issued only on the basis that
any statement made or to be made to the Insurer in respect of Insured Members and the group as a whole intended to be
insured there under shall be true and correct in every particular and we further agree that any misstatement or untrue averment
on the basis of which the insurances have been effected on the life of any Insured Member and/or the group as a whole shall
render voidable the particular insurance or insurances in respect of which the misstatement or untrue averment has been made
by whomsoever. We agree to co-operate fully with HDFC Life Insurance Company Limited in adherence with various
regulatory requirements pertaining to group insurance.

Signed for and on behalf of the Company/Group

Date: Signature
(Authorised Officer) [rubber stamp and address]

Witness:
Signature __________________
Name: ___________________
Address ___________________________________________________________________

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Prohibition of Rebate: In accordance with Section 41 of the Insurance Act, 1938 states as amended from time to time:

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 prospectus 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: In accordance with Section 45 of the Insurance Act, 1938 as amended from time to time. The extant
provisions in this regard are as follows:

(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 Master Proposal Form 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 Master Proposal Form.

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 Annexure 1
Data Format

Member data to be furnished by Master Policyholder in the following format:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
S. Name Date of Birth Gender Address Relationship Relationship Loan Loan Loan PAN …
No. Primary Joint Legal Primary Joint Legal Primary Joint Legal of Joint Life of Legal Account Account Type No.
Life Life Guardian Life Life Guardian Life Life Guardian with Guardian Number Number
Assured (if Assured (if Assured (if Member with 1 2
Member / Member / Member / Primary
Joint Life Joint Life Joint Life Life
Assured Assured Assured Assured/
is a is a is a Joint Life
minor) minor) minor)
1
2
3
…

18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
S. Sum Premiu Cover Mor Premiu Premiu Cover Main Interest Name Date of Gender % Share Contact Relationship
No Assur m Term atori m m Type Benefit Rate Birth Details with
ed (in um Payment Payment (Increa (%)
Mont Perio Option Frequen sing/
hs) d (in (Regular cy Decrea N N A N N A N N A N N A N N A PL N N1
yrs) / Single/ (Yearly/ sing) 1 2 P 1 2 P 1 2 P 1 2 P 1 2 P A 2 /2
Limited) Half
Yearly/
Quarterl
y/
Monthly
)
1
2
3
…
N1: Nominee 1
N2: Nominee 2
AP: Appointee
PLA: Primary Life Assured

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