SBI Life Insurance Co.

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

I. Income (Gross - Mandatory deduction) + Other income Rs.420000

as declared by proposer / investor

II. Accumulated Savings (STDR/TDR/RD/CASA Balance) Rs.0

III. Gross Annual Expenditure (Rs.) Rs.1200

IV. Occupation Organised Pvt. sector, Govt.

service, PSU

V. Date of Birth 17-04-1984

VI. Qualification Graduate

VII. Existing Ownership / Investments Insurance / MF Product :Not

Available

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.

Proposal No.: OL1H00099138191910122021122916 Channel/Intermediary CIF

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.

Proposer, Life Assured and Plan Details

Name of the Life Assured Mr. Kavya Nagesh

.
Age of the Life Assured 37
Vesting Age 47 Years
Sum Assured 0
Premium Payment Term 5
Policy Term 10 Years
Amount of Installment 1,00,000
Premium
Mode / Frequency of Premium Yearly
Payment
Total First Year Premium Rs. 1,00,000
Rate of Applicable Taxes 18%

Plan Option Advantage Plan

Fund Name (SFIN Name) % Allocation FMC Risk Level
Equity Pension Fund II (SFIN : 100% of Fund Value will be 1.35% High
ULIF027300513PEEQIT2FND111)

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)

How to read and understand this benefit illustration?

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

6 0 0 0 0 1266 840 1468 0 45045 0 0 608328 4727 603601 603601 612655

7 0 0 0 0 1297 840 1563 0 47977 0 0 647878 4800 643078 643078 652724

8 0 0 0 0 1327 840 1666 0 51128 0 0 690373 4865 685508 685508 695791

9 0 0 0 0 1357 840 1777 0 54516 0 0 736050 4921 731129 731129 742096

10 0 0 0 0 1386 840 1895 0 58159 0 11703 796870 4966 791904 791904 791904

Amount in Rs. Gross Yield 4% pa

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

6 0 0 0 0 1124 840 1280 0 20052 0 0 521523 4122 517401 517401 525162

7 0 0 0 0 1113 840 1313 0 20560 0 0 534696 4030 530666 530666 538626

8 0 0 0 0 1101 840 1347 0 21092 0 0 548470 3932 544538 544538 552706

9 0 0 0 0 1089 840 1382 0 21649 0 0 562876 3829 559047 559047 567433

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.

Definition of Various Charges:

1)Policy Administration Charges: a charge of a fixed sum which is applied at the beginning of each policy month by cancelling units for equivalent
amount, deducted for maintaining the policy.
2)Premium Allocation Charges: is the percentage of premium that would not be utilised to purchase units.
3)Fund Management Charge : is the deduction made from the fund at a stated percentage before the computation of the NAV of the fund.

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.

This document is eSigned by Mr. Kavya Nagesh .

Place :MYSORE
Date :10-12-2021

Marketing official's Signature & Company Seal

I, BHARAT SAHOO , have explained the premiums, charges and benefits under the policy fully to the prospect/policyholder.

(CIF code- 991381919)

Place :MYSORE Date :10-12-2021 Name of CIF- BHARAT SAHOO
Authenticated by Id & Password

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.

Proposal No. 1HND420783

Proposer/Accountholder Name* Mr. Kavya Nagesh .

(* In case of joint name, declaration to be provided by both the proposers. An accountholder is person who is entitled to
receive the cash value or change the beneficiary of the contract)

Mother's Name SHRI DEVI D

Spouse's Name NA

Residential Status Resident Indian

C-KYC number 50072197153604

Country of Birth India Place of Birth Mysore

GSTIN

Identification Aadhar Card Identification No XXXXXXXX07 Expiry Date NA

Proof 58
Address Proof AADHAAR Card No

In case you have selected “Service” as your occupation, Private Sector

please specify the nature of your Organization

Are you a tax resident of any country other than India? No

SI No Country/(ies) of Tax residency# Tax Identification number(TIN)/Functional Identification Type (TIN or other%,please
equivalent number% specify)

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.ver 06-06-19 ADD ENG 1

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

Certification - Under penalty of perjury, I certify that

• I am aware that Central Board of Direct Taxes (“CBDT”) has notified Rules 114F to 114H as part of the Income-tax
Rules, 1962, (read alongwith FATCA/CRS instructions given below) which require Indian financial institutions such as
SBI Life to seek additional personal, tax and beneficial owner information and certain certifications and documentation
from all our proposers/ accountholders.
• I understand that SBI Life is relying on information provided in this form for the purpose of determining the status of the
accountholder in compliance with FATCA/CRS. SBI Life is not able to offer any tax advice on FATCA or CRS or its
impact on me.
• I acknowledge my responsibility to seek advice from professional tax advisor for any tax questions.I agree to submit a
new form within 30 days if any information or certification on this form changes or becomes incorrect.
• I agree that as may be required by domestic regulators/tax authorities, SBI Life may be required to report, reportable
details to CBDT or other authorities/agencies or may be required to provide informations to any institutions such as
withholding agents for the purpose of ensuring appropriate withholding from the policy/(ies) or any proceeds in relation
thereto or even close or suspend my policy/(ies), as appropriate.
•I hereby declare that the details furnished in the proposal no. specified above and in this declaration are true and correct to
the best of my knowledge and belief and I undertake to inform SBI Life of any changes there in, immediately. In case any
of information furnished in the proposal no. specified above and in this declaration is found to be false or untrue or
misleading or misrepresenting, I am aware that I may be liable.
•I hereby authorize SBI Life to consider details furnished in the proposal no. 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 Central KYC Registry through SMS/Email or registered mobile number/email address
mentioned in the proposal no. specified above.
•I hereby authorize the Company to provide my/our details to banks, financial institutions and third party service providers
that the Company may have tie-ups with, for verification of proposal details and for servicing of resulting policy/(ies).

Signature of the Proposer

This document is eSigned by Mr. Kavya Nagesh .

Place :MYSORE Date :10-12-2021

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

FATCA-CRS.ver 06-06-19 ADD ENG 2

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

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.

FATCA-CRS.ver 06-06-19 ADD ENG 3

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

Proposal Number 1HND420783 Proposer Name Mr. Kavya Nagesh .

Aadhaar Consent Form

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

SBI LIFE INSURANCE COMPANY LTD.

COMMON PROPOSAL FORM
Registered & Corporate Office: Natraj, M. V. Road, & Western Express Highway Junction, Andheri (East), Mumbai - 400 069.
IRDAI Registration No. 111
Toll Free: 1800 267 9090(Between 9:00 AM & 9:00 PM) | Email: [email protected] | Website: www.sbilife.co.in | CIN:
L99999MH2000PLC129113

"IN CASE OF UNIT LINKED LIFE INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY
THE POLICYHOLDER"

SECTION ‘A’ PERSONAL DETAILS

A-1 a. Proposer (if different from Life Assured) / Life Assured / HUF Karta

First Name Kavya

Middle Name NA

Last Name Nagesh

Gender Male Date of Birth 17-04-1984 Age 37

Marital Status Married

Father's Name Mohan Vasudev

Mother’s Name SHRI DEVI D

Spouse’s Name NA

C-KYC No. 50072197153604

PAN Card No. AORPM9926J Form 60 NA

Age Proof Aadhar card with complete DOB KYC OVD (Officially Valid AADHAAR Card No
Document)

Identification Number XXXXXXXX0758

Resident Status Resident Indian

Nationality Indian Current Country of Residence India

Mobile Number 9964135208 Email Id

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

NCPF.ver.01-07-21 Digi PF ENG 1

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

Occupation Service

Force Name NA

Employee / Force No NA

Designation NA

Current place of posting(City and State) NA

For Defence personnel- Are you currently engaged or trained for future NA
involvement in any of the following?

Name of Employer / Workplace CUEMATH ONLINE SCHOOL MYSORE

Specify the exact designation teacher

Length of Service (Years) 30

Annual Total Income Rs. 420000

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.

Do you have any Criminal proceedings initiated No If Yes,please provide details NA

against you?

If previous question is yes then, Do you have NA If Yes,please provide details NA

any history of conviction under any criminal
proceedings in India or abroad?

e-INSURANCE ACCOUNT DETAILS

I want to receive the Insurance policy and all the information related to the proposed insurance No
policy through insurance repository.

Do you have e-insurance account? NA

If Yes, provide e-Insurance Account NA Repository Name NA

Number

• 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

1 Mr.Vihan N 27-12-2010 Male Son 100 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

NCPF.ver.01-07-21 Digi PF ENG 2

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

*Percentage share total should be 100%

APPOINTEE DETAILS :(Applicable in case nominee is Minor)

S.No Name Date of Birth Gender Relationship with Life Relationship with Signature/ Consent of
Assured Nominee Appointee

1 Mr. MOHAN 22-06-1950 Male Father Grand Father

VASUDEV

SECTION ‘A’ PERSONAL DETAILS

A-2 : Life Assured Details (Minor) / HUF Member (if different from Proposer)

First Name Kavya

Middle Name NA

Last Name Nagesh

Gender Male Date of Birth 17-04-1984 Age 37

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

Resident Status Resident Indian

Qualification Graduate

Current Country of Residence India

(also applicable for HUF member if different from Proposer)

"IN CASE OF UNIT LINKED LIFE INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY
THE POLICYHOLDER"

SECTION ‘B-1’ PRODUCT DETAILS

Product Code 1H Product Name SBI Life-Retire Smart

Plan Type LPPT Premium Plan Option Advantage Plan

Premium Frequency Yearly

(For Monthly mode, advance premium may be required, as mentioned in
the Benefit Illustration)

Are you a Staff or No If Yes please state: NA Spouse :PF/Pension NA

your spouse is Self :PF/Pension Index/ Employee No.
working/retired from Index/ Employee No.
State Bank Group?

Cover Details

Plan/Rider/option Policy Term(Yrs) Premium Payment SAMF Sum Assured(Rs) Premium Payable(Rs)
Term(Yrs)

SBI Life-Retire Smart 10 5 NA NA 100000

NCPF.ver.01-07-21 Digi PF ENG 3

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

Premium Payable 100000

Applicable Tax Amount*(Rs) 0

Total Installment Premium 100000

Payable(Rs)

* Taxes shall be applicable as mandated by Government of India from time to time.

Select: Product /Strategy /Options

Plan Name- SBI Life- Retire Smart Fund Options(Allocation % should total to 100%)

Plan Name- SBI Life Retire Smart Advantage Plan

Maturity/ Annuity/ Any other Option 1.2 Lifetime Income with Maturity/ Annuity/ Any other Monthly
option* Capital Refund option Frequency*

* Mandatory for Pension Products

SECTION ‘C-2a’ HEALTH AND OTHER DETAILS OF LIFE ASSURED:

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?

No. Health Details of Life Assured Y/N

1 Height 5Feet 3inches Weight 61 Kgs Have you lost No
weight of 5Kgs or
more in last 6
months

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”

a. Diabetes Mellitus/ High Blood No b. Heart Disease of any kind : No

Sugar, High/Low Blood Pressure Chest pain, Angina, Coronary
or High Cholesterol Artery Disease, heart attack, valve
disorder, Rheumatic heart disease,
conduction problem, or any other
disease of Heart, or undergone
Angiography, Bypass, PTCA,
Pacemaker implant etc

c. Lung /Respiratory disorder of No d. Cancer/ Malignancy diagnosed No

any nature: Asthma, COPD, or suspected: Cancer, Overgrowth,
Tuberculosis (TB), Pneumonia, Cyst, Tumor, Malignant growth ,
Bronchitis, emphysema, or any Leukemia, enlarged lymph node,
other chest or lung disease etc Lymphoma, or undergone
Chemotherapy, radiotherapy,
FNAC, Biopsy, Scan etc

e. Kidney, Prostate or No f. Disorder of Liver or other No

genitourinary Diseases : Kidney digestive organs : Alcoholic and
failure, infection, Stone, Other Liver disease, Jaundice,
Obstruction, or any other disease, Hepatitis of any type, Liver failure,
Dialysis, Transplantation or infection, enlargement, Cirrhosis,
removal of kidney , Blood in urine, Ascites etc or Gastric
or enlarge prostate, adrenal gland ulcer/bleeding, vomiting of blood,
disorder etc blood in stools, Piles, hernia,

NCPF.ver.01-07-21 Digi PF ENG 4

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

colitis, etc or any disease of

Esophagus, Pancreas, Gall bladder,
Spleen, Intestine, Rectum or any
digestive system or undergone
endoscopy, colonoscopy etc

g. Joints & Bone disorder, Vision No h. Brain or Spinal cord: Disorder No

or Hearing disorder, Deformity, of brain and/or spinal cord or
loss of organ or any congenital Nervous system, Hemorrhage,
defect: Arthritis (rheumatoid, bleeding, Tumor, stroke, paralysis,
ankylosying, Osteomylitis), gout, TIA, epilepsy/fits, seizures, coma,
deformity /disability, polio, any head injury, fainting loss of
disease of bone, joints, muscles, consciousness, tremors, impaired
spine , vertebral disc or, disorders movement of limbs, incontinence,
of eyes, ear, nose, throat, or or any other disorder of nerves or
amputation, absence or had MRI, CT scan etc
transplantation of organs etc

i. Psychiatric disorder: Mental No j. HIV or STD: Were you or your No

illness including, anxiety, spouse/partner test positive for
depression, schizophrenia, stress, HIV/AIDS or any other Sexually
Nervous breakdown, attempted Transmitted Disease?
suicide etc

k. Blood or hormonal No l. Current/ past general medical No

disorder(Thyroid etc) & others: condition Do you have any or in
Anemia, Bleeding or clotting last 5 years any, medical condition,
disorders, Autoimmune Disorder, symptoms , test results or
SLE, Lupus, thyroid disorder, procedure not asked above for
goiter, pituitary hormones disorder which you were/are under
etc treatment, observation or being
Hospitalized for more than 5 days
or were absent from work
continuously for more than 5
days, (excluding, common cold,
fever) or are you currently under
any medication?

o. Questions For Female Lives

1) Are you currently pregnant? NA If YES, kindly state expected NA

delivery date

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

Relation Alive(Yes/ No) Current Age/Age at Death Specify Nature of disorder

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

NCPF.ver.01-07-21 Digi PF ENG 5

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

NA NA NA NA

NA NA NA NA

4. Do you currently or have you in the past Smoked, Consumed Tobacco, No

Alcohol, any Narcotic or have ever been treated for complications arising
due to them?
If currently pursuing habit If Quitted
Habit Type Quantity Consuming since how long? Since how long? Consumed how long?
(Number of Years) (Number of Years) (Number of Years)
Smoking NA NA NA NA NA
Tobacco NA NA NA NA NA
Chewing
Alcohol NA NA NA NA NA
Narcotic NA NA NA NA NA

5. Do you take part in or do you No If Yes, please give details NA

have any intention of taking part in
any hazardous sports, hobbies,
activities or pursuits (e.g.
mountaineering, diving, racing or
aviation other than as a fare paying
passenger) that could be dangerous
in any way?

SECTION ‘C-2b’ Additional Questions For Female Lives

1. Husband's Annual Income(Rs) NA

2. Husband's Insurance Details
Name of Insurance Co. Yearly Premium(Rs) Sum Assured(Rs) Policy status

NA NA NA NA

SECTION ‘D’ CHANNEL DETAILS(For office use - to be filled by Sales Representative)

Channel Name Corporate Agency(SBG)

Is this Proposal sourced through No If Yes, please state the Distance NA

Distance Marketing? Marketing Mode

CIF Code 991381919 CIF Name BHARAT SAHOO

Bank/Broker/CA/IMF Code 00 Bank/Broker/CA/IMF Name STATE BANK OF INDIA

Worksite Code NA

Sourcing Branch Code 17797 Sourcing Branch Name SRIRAMAPURA 2ND STAGE-
MYSORE

For Institutional Alliances / Corporate Agency(SBG) only

Code 1 NA Code 2 NA Code 3 NA

Code 4 NA Code 5 NA Code 6 NA

SECTION ‘E-2’ PREMIUM & BANK DETAILS

NCPF.ver.01-07-21 Digi PF ENG 6

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

E-2 a. PREMIUM PAYMENT

GSTIN of policyholder NA

Is deposit for premium under this proposal paid by you Yes

If answer is No, please provide required information in the Proposal
Form

Source of premium funding Salary

Please note that SBI Life branches and its sales team are not authorised to collect cash from its customers

E-2 b. RENEWAL PREMIUM PAYMENT Auto Debit^

^Please fill the Auto Debit Mandate available at the end of the form for seamless payment of Renewal premium.

E-2 c. BANK ACCOUNT DETAILS OF PROPOSER/LIFE ASSURED

Account Number 62468795072 Account Type Savings

Bank Name STATE BANK OF INDIA Bank Branch Name SRIRAMAPURA 2ND STAGE
MYSORE

Name of Account Holder Mr Kavya Nagesh

IFS Code SBIN0017797

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 .

SECTION ‘F-2’ Declarations by the Proposer /Life Assured /HUF Karta :

• 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.

NCPF.ver.01-07-21 Digi PF ENG 7

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

• 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
.

NCPF.ver.01-07-21 Digi PF ENG 8

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM
 Proposal Number 1HND420783

Witness by (CIF code- 991381919)

Name of CIF- BHARAT SAHOO
Authenticated by Id & Password
Place :MYSORE Date :10-12-2021

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.

Non-Disclosure : Extract of Section 45, as amended from time to time,states

a). 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.
b). 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 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 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.
c). 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.
d). 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.

Place MYSORE Date 10-12-2021

Section 41 and 45 have to be verified at your end from the Insurance Act, 1938

NCPF.ver.01-07-21 Digi PF ENG 9

Authenticated via OTP shared for proposal no. 1HND420783 on 10-12-2021 12:53:10 PM