Professional Documents
Culture Documents
Proposal Form: Single Life Traditional Plans Full Underwriting
Proposal Form: Single Life Traditional Plans Full Underwriting
* The entire form is to be filled in black ink only. Use CAPITAL letters for information required in boxes with a space between words. Use separate proposal forms for
each plan. Any cancellation/alteration is to be signed by the proposed policyholder or life to be assured as appropriate.
* All relevant supporting documents are to be provided. Nomination should be done when proposal is on own life.
* 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.
* Where the proposed policyholder has not filled up the application form or where he/she has affixed the thumb impression, the corresponding declarations are to be
completed.
* Section B (questions 8, 10, 12, 14 & 15) and Section C (questions 2 and 3) are mandatory only where the life to be assured and the proposed policyholder are the
same. Details on Demat account & UID , Email, Pin code and Contact numbers are mandatory. Contact details mentioned herein will be used for future
communication.
* The plans mentioned in this proposal form have been approved by IRDA (Insurance Regulatory and Development Authority) and have been allotted an Unique
Identification Number (UIN). This number is available in our sales literature and also on IRDAs website for verification.
Notes: a) For any additional forms, annexes, questionnaires or drafts of declarations and affidavits, please contact your financial
consultant. b) Important sections to note under Insurance Act, 1938 are provided below
Section 45 Disclosure of material : No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of
commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall, after the expiry of two years from the date on which it
was effected be called in question by an insurer on the ground that statement made in the proposal or in any report of a medical officer, or referee, or friend of the
insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or
suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy-holder knew at the time of making it that
the statement was false or that it suppressed facts which it was material to disclose:
Provided that 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.
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: Provided that acceptance by an insurance agent of commission in connection with a policy of life
insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if at the time of
such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer. (2) Any person
making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.
License No:
Company Lead:
IA/CAO Emp No**
Channel code
Branch code:
Simultaneous Proposals:
No
Bancassurance Code:
Yes
No of Proposals sent together:
Credit Card
Cash
Payment Details:
Yes
Consolidated Payment:
Cheque
No
Form:
Yes
Signature of FC:
Yes
No
Page
Count
Particulars
Pan card
Received at
Age Proof
ID proof
Receipt No:
Client ID:
Address Proof
CCR
No of Simultaneous Proposals:
Income Proof
Pan Card
Bank Account/Bank Pass book Statement (Showing
transactions within last 6 months)
Questionnaire / Addendum
Address Verified (Mailing & Permanent)
Yes
No
Yes
No
Yes
No
SI Mandate
Yes
No
Comments:
Product Code:
CPP
Is PPH/LA an Employee:
No
To be filled in by Certified Financial Consultant **IA / CAO Insurance Associate / Corporate Agency Officer
Frequency
ClassicAssure Plus
Kindly submit completely filled Juvenile questionnaire if the age of Life to be assured is less than 12 years.
Subject to our prevailing operational rules, it may be required for Monthly Frequency to be taken with ECS/SI & and to pay first 3 months premium in advance along with the Proposal Form.
Please update the desired plan and additional benefits in the below table:
S.No.
1
30000000.00
Life Option
Additional benefit(s) (if any) (B)
32312.00
A
B
Total Premium including taxes (A+B)
For YoungStar Udaan, Select
32312.00
Benefit Option
Plan Option
Life
For Click 2 Protect Plus, Selected Plan Option
Policy Term (Yrs): 40
Premium Payment Term (for plans other then Super Income)
Benefit Term:
For Super Income Plan -
40
40
(Applicable if Benefit Term is less that Policy Term for Click2Protect Plus with Income Benefit Option)
Select
the Policy Term (PT), Premium Payment Term (PPT) & Payout Period (PP)
Options
PPT(Yrs)
PP(Yrs)
PT(Yrs)
Options
PPT(Yrs)
PP(Yrs)
PT(Yrs)
Option 1
16
Option 4
10
12
22
Option 2
10
18
Option 5
12
12
24
Option 3
10
10
20
Option 6
12
15
27
Commencement date:
Annual
(DD/MM/YYYY) (Has to be within the same financial year for backdated cases)
Payment Details:
CREDIT_CARD
Drawn on (Bank name):
Bank Account Number
Amount:
Date:
Cheque/DD No:
32312.00
18-Oct-2014
In case the life to be assured is the guardian of a disabled person, is this insurance policy being taken primarily to protect the disabled person?
UID Number:
MR
First Name:
Madhuresh
Middle Name:
Last Name:
Agrawal
Maiden Name:
(Only for married females)
Ankita Gupta
No
Proposer/policy holder other than individual please mention 'Legal name' in the Name column
3. Gender
Male
19-Oct-1985
6. Nature of Age Proof attached:
Pan card
4. Marital Status
Married
5. Nationality
Indian
7. Educational Qualification:
PGR
NO
10.PAN: AMSPA2689K
Not Applicable
PAN is mandatory for all applications where as on date of application, the cumulative amount of Premium and/ or
Single premium Top-up is equal to or exceed Rs 50000 in an financial year for a proposer.
13. If you are our existing life assured, assignee, nominee, proposers kindly enter Policy No(s):
Pan Card
Serial No:
Bank Account/Bank Pass book Statement (Showing transactions within last 6 months)
If address proof provided other than of self / spouse / father, then please specify the name of owner of residence
SMS
Office
Residence
Tele Calls
Permanent
Street / Area:
Sector 48
Landmark:
Sohna Road
City/District:
Gurgaon
State:
Pin Code:
122001
Haryana
Landmark:
City/District:
State:
Pin Code:
Gurgaon
Haryana
Mobile:
9971740123
Telephone No (O):
E-mail Address:
[email protected]
122001
Telephone No (R):
Fax No:
124-4949620
Business
100
House Property
0
Capital Gains
0
Investments
0
Agriculture
0
Others
Total
100%
NO
Definition of a Politically Exposed Person: Politically exposed persons are individuals who are or have been entrusted with prominent public functions in a foreign
country, their family members and close relatives such as Heads of States or of Governments, Senior politicians, Senior government/judicial/ military officers, Senior
executives of state-owned corporations, Important political party officials, etc
*HOUSEWIFE kindly submit Housewife Addendum 9 STUDENTS kindly state 1. The course being pursued 2. Name and address of college/institution (excluding coaching classes) 3.
Duration of the course 4. Year/semester/standard Address of present employer or business premises if self employed and address of registered office/main place of business in case of other
entities) 10 Proposer/policy owner is other than individual please mention Designation & fill Legal Form11Address of present employer or business premises if self employed and address of
registered office/main place of business in case of other entities
The exact nature of work performed by you (e.g. Clerical, mechanical, supervisory job, etc.)
Please provide details, if any, regarding your occupation or business, which may render you
susceptible to injury or illness. (e.g. exposure to chemical substances/hazardous materials/
harmful dust or gases/ explosives/ working at heights/ handling heavy machinery etc.)
No
Finance
4. Do you take part in any hobbies/activities that could be considered dangerous in any way?
e.g. aviation (other than as a fare-paying passenger),mountaineering, deep sea diving or any form of racing
No
Yes
No
Name of Countries
Duration
United States
Months
24
Months
6. Do you have any existing insurance cover of premium paying and/or paid up policies (excluding group term insurance plan taken by
your employer)?
No
If yes please fill details below
(i)Sum Assured payable on
death
(iii)Benefits on
disability /critical
illness
7. Have you submitted any simultaneous applications for life insurance at any of our offices or to another life insurance company,
No
which is still pending OR are you likely to revive lapsed policies?
Name of the company/ies
Sum Assured
payable on
death
Type of Products
Purpose Of cover
Proposed / To be revived
Declined
No
No
No
Withdrawn by self
No
Name of the
company/ies
Policy Number
Reason
9. Height
Cms (or)
5 Feet
Inches
10. Weight
69
Kgs.
11. Are you currently consuming or have you ever consumed any of the following:
Substance Consumed
Yes
No
Consumed As
Quantity
a. Alcohol
No
NA
b. Tobacco
No
NA
No
NA
NA
NA
NA
NA
(10) 1 unit equivalent to 330 ml of beer / 125 ml of wine/30 ml of spirits (11) 1 unit equivalent to 1 cigar/1cigarette/1 bidi. If chewing tobacco please specify how many grams per day.
NA
12. State the name and address of your usual doctor who attends you in the event of illness, OR if you have been consulting with this
doctor for less than 3 months, the name and address of your previous doctor.
Name:
House / Flat No:
Street / Area:
N/A
Pin Code:
City/District:
State:
Telephone No
Mobile:
Email:
13. Personal medical details:
Yes
No
Questionnaire
(a) Diabetes
No
(k) Stroke
No
No
No
No
No
(d) Epilepsy
No
No
No
No
(f) Arthritis
No
No
No
No
No
(i) Tuberculosis
No
No
No
No
No
No
No
No
No
No
No
No
If you have answered ''Yes'' to any of the sub questions [I (a to s), II, III, IV, V and VI] asked under question 13 of this section, please answer the
following
Nature of Illness/Accident
Date of
Diagnosis
/Event
Details of Investigations
Done
Under
Medication
(Yes/No)
Fully
recovered
(Yes/No)
Question (a) to (c) to be answered by female life to be assured below age 45 yrs only
(a) Are you presently pregnant?
(b) If Yes, how many weeks? Kindly attach the Pregnancy Questionnaire
(c) Have you ever had any disease of uterus, cervix, or ovaries?
(d) Have you ever undergone hysterectomy?*
* Please attach hysterectomy questionnaire and histopathology reports if answered as Yes
15. We may require you to undergo medical examinations/tests. Some of the medical tests may require you to observe fasting. Please indicate
your preference of location, near which the medical tests can be conducted.
Residence
Workplace
Yes
Heart disease, high blood pressure, stroke, diabetes, kidney disease, cancer?
If you have answered Yes to any of the questions above, please give details:
Relation to the life to
be assured
Father
Disease
Heart disease
Age of Diagnosis
48
Alive/Deceased
Alive
Current Age/Age at
death
59
Any form of paralysis, any hereditary disorder (such as Huntingtons disease, Polycystic disease of the kidney or familial polyposis of the
colon)
No
If you have answered Yes to any of the questions above, please give details:
Relation to the life to
be assured
Disease
Age of Diagnosis
Alive/Deceased
Current Age/Age at
death
Nominee
MRS
First Name:
Beneficiary
Gender:
Proposed Policyholder
Female
06-Dec-1988
Ankita
Middle Name:
Last Name:
Gupta
Wife
Same as stated on page 3, if different then please fill the fields below
Street / Area:
Sector 48
City:
Gurgaon
Pin Code:
122001
State/District:
Haryana
Mobile:
9910528877
0124-4949620
E-mail Address:
Gender:
First Name:
Middle Name:
Last Name:
Date of Birth:
Relationship to the nominee / beneficiary:
Correspondence Address
Same as stated on page 3, if different then please fill the fields below
Pin Code:
City/District:
Mobile:
E-mail Address:
Signature of appointee accepting the appointment:
(appointee cannot affix thumb impression)
SECTION E - DECLARATIONS
Declaration of the Life to be Assured and Proposed Policyholder:
I understand, agree and declare that - I have read and understood the product and the content of the proposal form. I have read the entire text, features, disclosures
and terms and conditions while applying for this policy. That the response to questions in this Proposal Form (also application) and all the information given by me
or on my behalf or in respect of the life to be assured (LA) in this application is true and I have not withheld or suppressed any material fact within my knowledge. I
consent that information provided by me including sensitive personal information (collectively "data") can be used / processed by HDFC Standard Life Insurance
Company Ltd. ("the Company") and its authorised associates, agents and service providers for the purpose of providing insurance services / products to LA and
transactions under the same . I consent to the Company seeking medical information from any doctor who at any time has attended LA regarding LA's physical or
mental health or seeking information from any other insurance company to which LA has applied for insurance. In the event of LA being medically examined, the
answers given to the medical examiner acting on behalf of the Company shall be deemed to be incorporated in this application. That these statements, and any
information or documents sought by the Company from any person authorized by me to provide such information, all declarations, affidavits and other statements
made by me and relied upon by the Company to assess the risk on LA under this application shall form the basis of the contract of insurance between myself and the
Company and shall be the basis of assessment, assumption and acceptance of risk by the Company. If any statement/information made/given by LA to you or to any
other person in connection with this application are inaccurate or false, or are found to be inaccurate or false, or if there is any non disclosure, withholding or
suppression of any fact pertaining to me or my health condition, physical or mental, or pertaining to financial position, as at the time of application, the Company shall
have the right to vary the benefits under the insurance policy or cancel the policy immediately by paying the applicable surrender value. The Company has the
absolute right either to accept or reject a proposal without giving reasons thereof and I undertake that there shall be no costs, claims, charges that will be raised by me
against the Company. I undertake to notify the Company any changes in LAs health condition or financial condition between the date of this application and prior to
acceptance of the risk by the Company. I understand the significance of the contract of insurance and that the contract will be governed by the provisions of the
Insurance Act, 1938 and the Indian Contract Act, 1872, and that the same will not commence until written acceptance of this application by the Company is received
by me. That the premium payable as well as the sum assured (main as well as additional/ rider benefits) may vary upon assessment of risk by the Company. That the
Company shall be entitled to retain the premium paid along with this application as an interest free initial deposit to be adjusted against premium payable upon issue
of the Policy. In the event of the application not being accepted by the Company the aforesaid deposit shall be refunded without any interest subject to permissible
deductions. That any statutory levy, taxes or charges including any indirect tax may be charged to me either now or in future by the Company and I agree to pay the
same. I confirm that in respect of unit linked insurance policies I have received the sales illustration provided by the Company in the prescribed manner and that I have
read and understood the same and further understand and accept the investment rate and that the rates assumed therein are not guaranteed. All/any amounts
paid/payable towards this Policy will be out of legally declared and assessed sources. I agree that the Company can peruse my financial profile and it can cancel this
contract if I am found guilty under any laws directly/indirectly relating to anti money laundering. Amounts paid, otherwise than from my account shall be permitted only
if an insurable interest can be established. I will provide information required by the Company, on its own or under any lawful instruction/ order, regarding sources of
funds/utilization/withdrawals. I agree to any of the information provided in the application, annexures thereto and the results of medical tests, if any, being made
available by the Company to any statutory authority or reinsurer(s), as well as to any other person or entity for the purposes of assessing the application/processing
any claim arising under the Policy. I declare and agree to be bound by the contents of this application and the information provided herein. All documents submitted
by me/us along with this application are authentic, valid, and where relevant true copies of originals for purpose of this application
Occupation
Mobile:
18/10/2014
Place :
9971740123
Date :
18/10/2014
Place :
Mobile:
Above signature and mobile number will be used for all future interaction and verification. Please provide your in-use mobile no. and sign as per your bank records/identity proof
submitted 14 Witness Signature, Address and Occupation is mandatory along with signature of LA / Proposed Policy
Note: 1.You may withdraw the consent till anytime before the proposal is logged into our systems. In that case, your proposal shall stand withdrawn by you. 2. The
data provided by you/LA and if subsequently found to be inaccurate, can be rectified upon a written request by you and as per our process except such data which
is the basis of this contract / policy unless agreed to by the Company.
Please contact us on any of the following touch points in case of non receipt of your HDFC Life policy document after 1month from date of application. Call us on
helpline number 18602679999 (do not pre fix any country code e.g. +91 or 00), SMS SERVICE to 5676727 for call back request or email us at
[email protected].
Note: Please retain your copy of the acknowledgement slip for future references
Declaration to be made by a 3rd person where:
The proposed policyholder has affixed his/her thumb impression; OR
The proposed policyholder has signed in vernacular; OR
The proposed policyholder has not filled the application.
I hereby declare that I have explained the contents of this application form to proposed policyholder in____________________________________language and have
truthfully recorded the answers provided to me. I further declare that the proposed policyholder has signed/affixed his/ her thumb impression in my presence.
Signature
Date:
18/10/2014
Request for maintenance of standing instruction for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select banks only)
X Request to remit bill amount for premium payment to HDFC Standard Life Insurance Co. Ltd. through Electronic Clearing Service (for select
cities only).
Request for direct debit from my bank account (non ECS location) for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select
banks only*)
Preferred billing date:
(DD/MM) *
Policy No. :
Policy number
---------------------------------------------------------------------------------------------------------------------------------CUSTOMER ACKNOWLEDGEMENT
Date:
Plan Name
Cheque / DD
Frequency of Payment
Amount (Rs.)
Term
Bank
2.
3.
I,
have collected the above documents and will be submitting it tothe nearest HDFC
Standard Life branch for further processing.
(Signature of Financial Consultant)
(Financial Consultant contact number)
Financial Consultant Code)
> This is NOT A PAYMENT RECEIPT but only a proof of the documents received from you. > All cheques/DD should be crossed and drawn in
favour of HDFCSLIC. > If payment is not made by way of Cheque/DD, Kindly make cash payment at an HDFC Standard Life branch and collect
your initial deposit receipt. > This acknowledgement does not in any way constitute acceptance or commencement of risk.
Easy Connect: If you have any queries or clarifications regarding your policy, kindly contact us at any of the following service touch points accessible from 9 am to
9 pm all 7 days, alternatively you may e-mail us at [email protected]
@ Call 1800 266 0315 tol free
SMS service to 5676727
Dear _______________, we acknowledge the receipt of your SI/ECS mandate and it will be processed within 30 days from today. After attaching the same in our system, we will forward it to your
bank for further processing. In case of rejection, the same would be communicated to you; or else it would mean that your mandate is lodged in successfully.
Effective the next due date the premium would be debited from your bank account. Thank you for choosing direct debit as your premium payment option.
Branch Stamp
Acknowledgement received
(Signature of the Customer)
Continued Overleaf
Note:
* Premium can be paid out of your own account or out of your Spouse, Parent or Childrens Account only. * Any cancellation, correction, alteration
etc. should be countersigned by the Account Holder. * Kindly ensure that the SI mandate form is signed by the account holder, even if the account
holder is different from the policy holder. * If the bank is unable to debit the account of the Policy Holder due to want of sufficient funds, the policy
holder will have to pay the premium by cheque/DD or cash at any of the branches of HDFC Standard Life Insurance Co. Ltd. before the grace
period ends, failing which the policy will lapse with/without a surrender value as applicable. * HDFC SL has the right to revoke the Standing
Instruction on event of the Instruction or change in the premium amount due to any alteration. * Direct debit facility (non ECS location) is offered by
ICICI Bank, Citibank, Corporation Bank, Union Bank of India, Bank of Baroda and Axis Bank only.
To be filled in by the account holders bank
Bank Stamp
Date
Hassle Free Options: Your policy portfolio now available at your fingertips!
My Account- your very own customer portal
NRI Q - 6.6
FC Code No:
We thank you for applying for an HDFC standard Life Insurance Policy. To enable us to assess your application, kindly send this NRI/ Person of
Indian Origin Questionnaire answered by the Life to be Assured and duly signed by the Life to be Assured and Proposed Policy Holder, if any.
S100000134668
Madhuresh
4. Nationality
INDIAN
Sector 48
Gurgaon
INDIA
3.Similarly, the claim proceeds under such policies will be paid in India in Indian Currency.
4.The product has been sold to me in India and the proposal from is being signed by me in Indian territory.
Signature/thumb impression
(Life to be Assured)
Signature/thumb impression
(Proposed Policy Holder if different
Date:
Place:
Date:
Place:
I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language and have truthfully recorded the
answers provided to me and that the Life to be Assured has signed /affixed thumb impression(s) above after fully understanding the contents
thereof.
Signature
Date:
Place:
In case of further clarification please contact your FC/ BDM/ CAM/ HDFCSL Branch office.
e-Insurance Account (eIA) Opening Form for Individual - To be used only if submitted along with the proposal form
Application No. / Proposal
S100000134668
A. Select the preferred insurance repository in which e-Insurance Account (eIA) needs to be opened:
Gender*:
Email ID*:
Mobile No*:
Address*:
Same as eIA
,,
City:
Pincode:
State:
Country:
I wish to notify Authorized Representative about his/her appointment
Declaration
The rules and regulations of Insurance Regulatory and Development Authority & Insurance Repository pertaining to an e-Insurance Account
which are in force now have been read by me and I have understood the same and I agree to abide by and to be bound by the rules as are in
force from time to time for such e-Insurance Account. I hereby declare that the particulars given herein are true, correct and complete to the
best of my knowledge and belief, the documents submitted along with this application are genuine and I am not making this application for the
purpose of contravention of any Act, Rules, Regulations or any statute or legislation or any Notifications, Directions issued by any
governmental or statutory authority from time to time. I authorise the Insurance Repository to send any policy and account related information
through email and SMS on the contact details given by me. In case of any physical policies being issued by the Insurance Company from
whom I obtain an epolicy, the address in the e-Insurance Account shall override the address provided for the physical policies. I understand
that all the communication relating to any physical/ e-policy will be sent to the address registered with the Insurance Repository. I agree to
inform the Repository of any changes in the details mentioned in this form and in case of delay the said repository shall not be liable in case it
acts on the said information which has not been updated. Further, in case I update the details with the Insurance Company, I authorise them to
submit the same to you for update in the e-Insurance Account and the said update will be applicable to all policies of any insurer that I hold/ will
hold in the said account. I authorise the Repository to pass on the information to any Insurance Company that I have approached for availing of
insurance cover.
I further agree that any false / misleading information given by me or suppression of any material fact will render my e-Insurance Account liable
for termination and further action.
I hereby authorise the Insurance Repository / Insurance Company to disclose, share, remit in any form, mode or manner, all / any of the
information provided by me to the respective Insurance Companies and / or to their authorised agents and representatives in which I may
transact / have transacted including all changes, updates to such information as and when provided by me.
I hereby agree to provide any additional information / documentation that may be required by the Authorised Parties, in connection with this
application. I hereby confirm that this is a unique e-Insurance Account opening application and I have not applied to the same Insurance
Repository or any other Insurance Repository for an e-Insurance Account in the past.
I would like to receive my insurance policy and all the information related to the proposed insurance policy through Insurance Repository.
I am aware the details furnished by me, including KYC documents, in/alogwith the proposal form will be used to open the eIA. I hereby give my
consent for the same.
Signature
Call 1860-267-9999 (Local charges apply). DO NOT prefix any country
code e.g. +91 or 00. Call centre is open all 7 days from 9am to 9pm
SMS - SERVICE to 5676727 (Charges apply)
Email [email protected]
Visit www.hdfclife.com