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 -Retire Smart 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. Kavya Nagesh .
Account No.: 62468795072
Mobile No.: 7680074608
Email ID:
Date: 10-12-2021
Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
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)
Customised Benefit Illustration (CBI)
SBI Life - Retire Smart (111L094V02)
An Individual, Unit-linked, Non-Participating, Pension Savings Product
IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.
Insurance Regulatory & Development Authority of India (IRDAI) requires all life insurance companies operating in India to provide official illustrations to their customers. The illustrations are based
on the investment rates of return set by the Life Insurance Council (constituted under Section 64C(a) of the Insurance Act 1938) and is not intended to reflect the actual investment returns achieved or
which may be achieved in future by SBI life Insurance Company Limited. All life insurance companies use the same rates in their benefit illustrations.
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, its benefits and applicable charges please refer to the sales brochure and/or policy document.
Bond Pension Fund II (SFIN : distributed among the three funds 1.00% Low to Medium
ULIF028300513PENBON2FND111)
Money Market Pension Fund II (SFIN : as per term to maturity 0.25% Low
ULIF029300513PEMNYM2FND111)
This benefit illustration is intended to show what charges are deducted from your premiums and how the unit fund, net of charges and taxes, may grow over the years of the policy term if the fund earns
a gross return of 8% p.a. or 4% p.a. These rates, i.e. 8% p.a. and 4% p.a. are assumed only for the purpose of illustrating the flow of benefits if the returns are at this level. It should not be interpreted
that the returns under the plan are going to be either 8% p.a. or 4% p.a.
Net yield mentioned corresponds to the gross investment return of 8% p.a., net of all charges but does not consider guarantee charges. It demonstrates the impact of charges exclusive of taxes on the net
yield.
The actual returns can vary depending on the performance of the chosen fund. The investment risk in this policy is borne by the policyholder, hence, for more details on terms and conditions please read
the sales literature carefully.
Part A of this statement presents a summary view of year- by- year charges deducted under the policy, fund value, surrender value and the death benefit, at two assumed rates of return. Part B of this
statement presents a detailed break-up of the charges, and other values.
Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
PART A
Amount in Rupees At 4% p.a. Gross Investment return At 8% p.a. Gross Investment return
Policy year Annualized Mortality Other Charges* Applicable Fund at end of Surrender Value Death Benefit Mortality Other Charges* Applicable Fund at end of Surrender Value Death Benefit Commission
Premium charges Taxes the year charges Taxes the year payable to
intermediaries
(Rs)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 100000 0 7599 1368 94721 88015 105000 0 7626 1373 98375 91410 105000 5000
2 100000 0 7459 1343 193437 188717 210000 0 7567 1362 204771 200051 210000 2000
3 100000 0 8604 1549 294732 291192 315000 0 8851 1593 318121 314581 322893 2000
4 100000 0 10031 1806 398365 396005 420000 0 10482 1887 438546 436186 445125 2000
5 100000 0 11219 2019 504716 504716 525000 0 11913 2144 566857 566857 575360 2000
6 0 0 6243 1124 517401 517401 525162 0 7035 1266 603601 603601 612655 0
7 0 0 6183 1113 530666 530666 538626 0 7203 1297 643078 643078 652724 0
8 0 0 6119 1101 544538 544538 552706 0 7371 1327 685508 685508 695791 0
9 0 0 6051 1089 559047 559047 567433 0 7538 1357 731129 731129 742096 0
10 0 0 5978 1076 582838 582837 582837 0 7701 1386 791904 791904 791904 0
Annuity Option Selected (The option can be changed any time before vesting) Option 1.2 Lifetime Income with Capital Refund
Fund Value (FV) at Vesting Annuity Payable p.a.
Accumulated at 4% p.a.Rs. Accumulated at 8% Minimum Assured Benefit, if any Based on FV Based on FV Based on the Minimum Assured Benefit, if
p.a.Rs. accumulated at 4% accumulated at 8% any(Rs.)
Rs. Minimum return on the p.a.Rs. p.a.Rs.
premiums paid % p.a.
582837 791904 505000 32434 44068 28103
* See Part B for details
The values shown above are for illustration purpose only. This illustration is based on an annuity rate of 53.64 per INR 1000 vesting amount. We do not guarantee the annuity rates. The actual annuity amount depends on the prevailing annuity rates at the time of vesting. The amounts of
annuity based on the assumed investment return of 8% p.a & 4% p.a. are not upper or lower limits of what you might get back. For details on risk factors, terms and conditions, please read sales brochure carefully.
IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICYHOLDER AND THE ABOVE INTEREST RATES ARE ONLY FOR ILLUSTRATIVE PURPOSE
PART B
Amount in Rs. Gross Yield 8% pa Net Yield 6.50%
Policy Year Annualized Premium Annualized Mortality Applicable Policy Admin Guarantee Other Additions to Guaranteed Terminal Fund before FMC Fund at End Surrender Death benefit
Premium Allocation Premium - charge Taxes charge charge charges* the fund* Addition Addition FMC of year Value
(AP) Charge (PAC) Premium
Allocation
Charge
1 100000 5750 94250 0 1373 540 240 0 7373 0 0 99471 1096 98375 91410 105000
2 100000 4250 95750 0 1362 540 499 0 15324 0 0 207048 2277 204771 200051 210000
3 100000 4000 96000 0 1593 540 775 0 23795 0 0 321657 3536 318121 314581 322893
4 100000 4000 96000 0 1887 540 1069 0 32794 0 0 443419 4873 438546 436186 445125
5 100000 4000 96000 0 2144 540 1381 0 42368 0 0 572849 5992 566857 566857 575360
10 0 0 0 0 1386 840 1895 0 58159 0 11703 796870 4966 791904 791904 791904
Policy Year Annualized Premium Annualized Mortality Applicable Policy Admin Guarantee Other Additions to Guaranteed Terminal Fund before FMC Fund at End Surrender Death benefit
Premium Allocation Premium - charge Taxes charge charge charges* the fund* Addition Addition FMC of year Value
(AP) Charge (PAC) Premium
Allocation
Charge
1 100000 5750 94250 0 1368 540 235 0 3687 0 0 95794 1073 94721 88015 105000
2 100000 4250 95750 0 1343 540 480 0 7517 0 0 195626 2189 193437 188717 210000
3 100000 4000 96000 0 1549 540 731 0 11448 0 0 298065 3333 294732 291192 315000
4 100000 4000 96000 0 1806 540 988 0 15469 0 0 402869 4504 398365 396005 420000
5 100000 4000 96000 0 2019 540 1251 0 19589 0 0 510144 5428 504716 504716 525000
10 0 0 0 0 1076 840 1419 0 22231 0 8614 586557 3719 582838 582837 582837
Notes :
1) Refer the sales literature for explanation of terms in this illustration.
2) Please read this benefit illustration in conjunction with Sales Brochure and the Policy Document to understand all Terms, Conditions & Exclusions carefully.
3) Kindly note that above is only an illustration and does not in any way create any rights and/or obligations. The actual experience on the contract may be different from what is illustrated. The non-
guaranteed low and high rate mentioned above relate to assumed investment returns at different rates and may vary depending upon market conditions. For more details on risk factors, terms and
conditions please read sales brochure carefully.
4) The unit values may go up as well as down and past performance is no indication of future performance on the part of SBI Life Insurance Co. Ltd. We would request you to appreciate the
associated risk under this plan vis-à-vis the likely future returns before taking your investment decision.
5) It is assumed that the policy is in force throughout the term.
6) Fund management charge is based on the plan option
7) Surrender Value equals the Fund Value at the end of the year minus Discontinuance Charges. Surrender value is available on or after 5th policy anniversary.
8) Acceptance of proposal is subject to Underwriting decision.
9) 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/ or any other charges as per the product features.
Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
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.
Your SBI LIFE -Retire Smart (111L094V02) is a LPPT Premium Policy and you are required to pay Yearly Premium of Rs. 100,000 .Your Policy Term is 10 years Premium Payment Term is 5 years
I, Mr. Kavya Nagesh . have received the information with respect to the above and have understood the above statement before entering into a contract.
Place :MYSORE
Date :10-12-2021
I, BHARAT SAHOO , have explained the premiums, charges and benefits under the policy fully to the prospect/policyholder.
Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
Proposal Number 1HND420783
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.
Spouse's Name 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. Kavya Nagesh ., 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 MYSORE
Date 10-12-2021
4
Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
Proposal Number 1HND420783
"IN CASE OF UNIT LINKED LIFE INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY
THE POLICYHOLDER"
Middle Name NA
Spouse’s Name NA
Age Proof Aadhar card with complete DOB KYC OVD (Officially Valid AADHAAR Card No
Document)
I hereby authorize SBI LIFE to send, any information/communication relating to this proposal/or the resulting policy through SMS /Email /Phone
/Letter /WhatsApp /any other electronic mode of communication to my registered email id/mobile number.
Qualification Graduate
CONTACT DETAILS
Address 1 C/O, Srirampura 2nd Stage 18, 1st floor, Block 24 BEML layout
Sri Rampura 2nd Stage Sri Ramp ura 2nd Stage-MYSORE, 570023,
KARNATAKA, India
Communication address if different from above? (If Yes, then the Yes
following to be filled)
Communication Address (Address 2) C/O, 18 Srirampura 2nd Stage 1st floor, Block 24 , BEML layout
Sri Rampura 2nd Stage Sri Ramp, ura 2nd Stage-MYSORE,
570023, KARNATAKA India
Occupation Details
Occupation Service
Force Name NA
Employee / Force No NA
Designation NA
For Defence personnel- Are you currently engaged or trained for future NA
involvement in any of the following?
Are you exposed to any special hazard No If Yes, please provide details NA
associated with your occupation which may
render you susceptible to injuries or illnesses?
(e.g. chemical factory, mines, explosives,
corrosives, combative duties, oil exploration,
high sea voyage etc.)
Are you a “Politically Exposed Person” (PEP) No If Yes, please provide details NA
or a close relative of PEP?
PEPs are individuals who are or have been
entrusted with prominent public functions, i.e.
heads / ministers of central / state govt., senior
politicians, senior govt, judicial or military
officials, senior executives of govt. companies,
important political party officials, immediate
family member of above persons (would
include spouse, parents, siblings, children,
spouse’s parents or siblings and close associates
of PEPs.)The definition includes foreign as well
as domestic PEPs.
If No, in case your PEP status changes in
future, you shall inform SBI Life Insurance Co.
Ltd. of such a change.
I want to receive the Insurance policy and all the information related to the proposed insurance No
policy through insurance repository.
• If No : Request to select any one insurance repository from below options:Repository Name : NA
NOMINEE DETAILS (Not applicable for Minor Life Assured / HUF Member)
S.No Name Date of Birth Gender Relationship with Life Percentage Share (%)* Address same as Life
Assured Assured’s Address
(Yes/No) If No, then
please provide
S.No Name Date of Birth Gender Relationship with Life Relationship with Signature/ Consent of
Assured Nominee Appointee
A-2 : Life Assured Details (Minor) / HUF Member (if different from Proposer)
Middle Name NA
Relationship with Proposer Life Assured is same as Proposer Age Proof Aadhar card with complete DOB
Is Life Assured address same as the Proposer’s Address?(If No, then fill C/O, 18 Srirampura 2nd Stage 1st floor, Block 24 , BEML layout
below ) Sri Rampura 2nd Stage Sri Ramp, ura 2nd Stage-MYSORE,
570023, KARNATAKA India
Nationality Indian
Qualification Graduate
Cover Details
Plan/Rider/option Policy Term(Yrs) Premium Payment SAMF Sum Assured(Rs) Premium Payable(Rs)
Term(Yrs)
Maturity/ Annuity/ Any other Option 1.2 Lifetime Income with Maturity/ Annuity/ Any other Monthly
option* Capital Refund option Frequency*
Do you have any other individual existing life insurance policy (from SBI Life or any other No
life insurer) or have you applied for any cover other than this SBI Life proposal? If Yes,
please provide details below
Name of Insurance Co. Yearly Premium(Rs) Sum Assured(Rs) Self/Spouse/Parent(pls. Specify) Policy Status
NA NA NA NA NA
Has any of your proposals for No If Yes, then provide the details NA
life/health/accident insurance ever
been declined /rejected, postponed,
withdrawn, or accepted with extra
premium?
2. Have you ever been treated, hospitalized, investigated or diagnosed or operated for any of the following (including but not limited to the specific
conditions mentioned under each category).Every point should be answered in “yes” or “no”
2) Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, NA
fallopian tubes, menstruation, complications during pregnancy or child delivery or undergone any
gynecological investigations for illness, internal checkups, breast checks such as smear Test,
mammogram or biopsy etc
If any of the above questions is ticked "Yes" (1 -2) 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 DD/MM/YYYY planned
NA NA NA NA
3. 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
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
Worksite Code NA
Sourcing Branch Code 17797 Sourcing Branch Name SRIRAMAPURA 2ND STAGE-
MYSORE
GSTIN of policyholder NA
Please note that SBI Life branches and its sales team are not authorised to collect cash from its customers
^Please fill the Auto Debit Mandate available at the end of the form for seamless payment of Renewal premium.
Bank Name STATE BANK OF INDIA Bank Branch Name SRIRAMAPURA 2ND STAGE
MYSORE
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 hereby authorize SBI Life to directly credit any payment/refund, if any, to the above
mentioned account.
Note: Please ensure that the Bank details provided are correct and complete. Please note that SBI Life shall not be responsible if any payments to the
Bank account number provided by you fail on the ground that the bank details provided are incorrect.
This document is eSigned by Mr. Kavya Nagesh .
• I hereby declare that I have answered the questions in the Proposal Form after having fully understood the nature of the questions and importance of
disclosing all correct information. I further declare that the statements, answers and/or particulars given by me are true and complete in all respects to the
best of my knowledge and I have not concealed any material information which may affect the decision of SBI Life Insurance Company Ltd. (the
Company) to assess the risk. I understand that the information provided by me will form the basis of the insurance policy. All documents submitted by
me along with this Proposal Form are authentic, valid, and I declare that relevant true copies of originals for the purpose of this Proposal Form have been
submitted.
• 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 void subject to the provisions of section 45 of the
Insurance Act, 1938, as amended from time to time.
• I declare that I have received and fully understood the Product Brochure and Benefit Illustration of the plan of insurance under which I have applied for
a Policy on the Life to be Assured. Further, I accept that the investment rates assumed under the Benefit Illustration are not guaranteed and the actual
benefits under the policy will vary from those shown in the Benefit Illustration.
• I agree that after the date of submission of this proposal but before the acceptance of risk or issue of the policy document by the Company (i) if there are
any adverse circumstances connected with my occupation, financial condition, health condition, or (ii) if a proposal for assurance on my life or on the
life to be assured made to any other insurance company has been withdrawn or dropped or accepted at an increased premium or on terms other than as
proposed by me, I shall forthwith intimate the same to the Company, in writing to reconsider the terms of acceptance of this proposal. Any omission on
my part to do so shall render the contract of assurance invalid. The Company reserves the right to accept, decline or offer alternate terms on my/our
proposal for Life/Health Insurance.
• I understand and agree that, the PROPOSAL WILL NOT BE CONSIDERED UNTIL THE FULL PREMIUM INCLUDING TAXES, IS PAID BY ME.
• I understand and agree that The risk cover under this proposal shall commence only after the risk under the Proposal Form is accepted by the Company
and such acceptance is communicated to me in writing by the Company. 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 hereby confirm that all premiums will be paid from my bonafide sources and in accordance with the provisions of the Prevention of Money
Laundering Act 2002 (as amended from time to time) or any other applicable laws.
• 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 hereby voluntarily give my consent to collect, process, receive, possess, store, deal or handle my/our sensitive personal data or information [as defined
in the Information Technology (Reasonable security practices and procedures and sensitive personal data or information) Rules 2011 as amended from
time to time], and share Data with third parties/ vendors associated with the Company for various purposes and outsourced activities exclusively related
to issuance/servicing/settlement of claim as required under the Policy.
• I agree and authorize(i) my past and present employers / business associates, any doctor/medical examiner / hospital / laboratory / clinic / insurance
company (notwithstanding any usage or custom or rules/ regulations of such hospital or laboratory or clinic) to disclose and furnish such documents
regarding my employment/business, my health and habits or health and habits of the Life to be Assured (without taking the prior consent of my family or
of any member thereof) to the Company as it may require either for the purpose of processing my proposal for insurance or at any time thereafter for any
other purpose in relation to the Policy that may be issued in pursuance of this proposal for insurance (ii) the Company may, without any reference to me
or my family or any member thereof, furnish any details/ information furnished in this Proposal Form to any judicial or statutory or other authority or to
any insurer or reinsurer in connection with the processing of this proposal for insurance or for the purpose of servicing and settlement of claims of
resultant policy.
• I hereby authorize the Company to assess the health status and conduct screening / confirmation / telephonic verification/reconfirmation of the life/lives
to be assured including the health status through medical examinations which may include Laboratory tests, Cardiology, Radiological investigations and
other medical tests including blood tests to detect bacterial/viral/fungal infections if required by the Company. I hereby give my consent to undergo
HIV1/2 test. I am aware that this test is only for screening purpose and not confirmatory for HIV/AIDS.
• I understand and agree that the insurance contract will be governed by the provisions of the Indian Insurance Act 1938, IT Act 2000, and the Indian
Contract Act, 1872, as amended from time to time, and all other applicable statutes and prevailing laws in India as amended from time to time.
• I hereby authorize the Company to provide/receive my details to/from 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 / We hereby authorise the Bank or financial institution to provide copy of my/ our KYC documents available with them to the Company.
• 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 hereby consent to receiving information from Central KYC Registry through
sms/ email on the above registered number/email address.
• I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any
changes in KYC related data therein, immediately. In case any of the information is found to be false or untrue or misleading or misrepresenting, I am
aware that I may be held liable for it.
• This consent shall hold good even if I register my number with the National Customer Preference Register (NCPR). I agree that the information
pertaining to my proposal or policy will be sent to the mobile number given in the proposal form or to the number subsequently changed by me.
• 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 am aware that SBI Life-Retire Smart is a Limited premium policy and I am aware that I would need to pay premium for 5 years (Premium Payment
Term) and have selected the product & the options applicable/available for me.
• 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.
Signature of the Proposer
This document is eSigned by Mr. Kavya Nagesh
.
Prohibition of Rebates : Section 41 of the Insurance Act, 1938, as amended from time to time,states
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.
Section 41 and 45 have to be verified at your end from the Insurance Act, 1938