Proposalform
Proposalform
Proposalform
ALL UNIT LINKED POLICIES ARE DIFFERENT FROM TRADITIONAL INSURANCE POLICIES AND ARE SUBJECT TO DIFFERENT RISK FACTORS.
IN UNIT LINKED POLICY THE INVESTMENT RISK IN YOUR CHOSEN INVESTMENT PORTFOLIO IS BORNE BY YOU Photograph of life to be assured*
to be signed across by the life to
be assured
* Not mandatory if life to be
assured is different from the
1) The entire form is to be filled in black ink only by the policyholder. Use CAPITAL letters for information required in boxes with a space between Proposer except if Life to be
assured is minor
words. 2) Any cancellation / alteration is to be signed by the proposed policyholder or life to be assured as appropriate. 3) All information provided here
shall be relied on and should be accurate, complete and true in all respects for processing the proposal quickly. In case you have any doubt whether the
particular information is material or not, please disclose the information. 4) Please attach an extra sheet, wherever additional information is to be given.
Proposer (Primary Life to be Assured)/ Policy Owner Details (Proposer in case of Click 2 Wealth for Premium Waiver Option)
1. Full Name:(Leave a blank Mr. SHIVAM KUMAR
space between First, Middle &
Last Name)
2. Maiden Name:(for married woman
only)
Country of Residence:
If NRI/PIO/OCI
Country of Workplace:
If NRI/PIO/OCI
Permanent Country:
9. Do you have an existing HDFC No If Yes, please provide Policy NO: Annualised Premium:
Life policy:
10. Does your spouse have an If Yes, please provide Product
existing HDFC Life policy: Name:
11. Are You an employee of HDFC If Yes, please provide Employee Relationship with HDFC Group
Group or Spouse/child of HDFC ID: Employee(if applicable)
Group employee:
12. Correspondence SHANKAR CHOWK WARD NO 18, BHABDEPUR, NEAR GIRLS MIDDLE SCHOOL
Address: Sitamarhi, Bihar-843302 India
13. Permanent Address (If SHANKAR CHOWK WARD NO 18, BHABDEPUR, NEAR GIRLS MIDDLE SCHOOL
different from Sitamarhi, Bihar-843302 India
correspondence address)/
Overseas residential
address for NRI / PIO / OCI :
14. Mobile: 919035180512
Telephone No(R):
Telephone No(O):
E - mail ID: SHIVAMSONI2754@GMAIL.COM
Email ID if provided, will be
considered as preferred mode of
communication
23. Do you have any history of conviction / acquittal under any criminal proceedings in India or abroad? No
24. Sources of Funds: If Premium & Single Premium Top-ups, if any is equal to or more than INR 1 lakh, please enclose proof of income e.g. ITR
Salaries Business House Property Capital Gains Investments Agriculture Others Total
100% 100%
Details of Secondary Life to be Assured (Life Assured in case of Click 2 Wealth for Premium Waiver Option)
1. Full Name: (Leave a Mr. SHIVAM KUMAR
blank space between First,
Middle & Last Name)
2. Maiden Name:(for married
woman only)
Country of Residence:
If NRI/PIO/OCI
Country of Workplace:
If NRI/PIO/OCI
Permanent Country:
12. Mobile: 919035180512
Telephone No(R):
Telephone No(O):
E - mail ID: SHIVAMSONI2754@GMAIL.COM
Email ID if provided, will be
considered as preferred mode of
communication
Preferred language of
communication:
13. Present Occupation: Salaried
14. Gross Yearly Income 11,50,000
(INR):
15. Workplace Name and Societe generale Global solution centre pvt.ltd, Bangalore, Bangalore,
Address:
^ please provide name of last
organisation
22. Do you have any history of conviction / acquittal under any criminal proceedings in
India or abroad? No
23. If Life to Assured is a student/housewife, please provide insurance details regarding
parents/husband/siblings.
(Please attach a separate sheet for multiple policies if required.)
Total Sum Assured of all Policy No. and Name of Husband's / Parent's
inforce life insurance Company Occupation / Income
policies
Personal Details of Life to be Assured (Primary) (Proposer in case of Click 2 Wealth for Premium Waiver Option)
1 Please provide details, if any, regarding your occupation or business, which may render you susceptible to injury or illness. None of these
(e.g. exposure to chemical substances/hazardous materials/harmful dust or gases/ explosives/ working at heights/ handling
heavy machinery etc.)
2 Do you have any existing insurance cover of premium paying and/ or paid-up policies? N
3 Have you submitted any simultaneous applications for life insurance to another life insurance company, which is still pending Neither of these
or are you likely to revive lapsed policies.
4 Has any application for insurance on your life been postponed? N
5 Has any application for insurance on your life been accepted with extra premium? N
6 Has any application for insurance on your life been accepted on other special terms? N
7 Has any application for insurance on your life been declined? N
8 Has any application for insurance on your life been withdrawn by you? N
9 Have you resided overseas for more than six months continuously during the last five years? N
10 Do you intend to reside overseas in the next six month N
11 Do you take part in any hobbies/ activities that could be considered dangerous in any way? E.g. aviation (other than as a fare- N
paying passenger), mountaineering, deep sea diving or any form of racing.
12 Have you ever suffered from: Diabetes/ high blood sugar/ sugar in urine,High blood pressure/ hypertension,Heart N
disease,Stroke
13 Have you ever suffered from:Respiratory disorders,Arthritis,Back problems,Tuberculosis,Any recurrent medical condition, N
disability. (Including eye/ ear disorder)
14 Have you ever suffered from: Liver disorder,Kidney disorder,Disorder of the digestive system,Abnormality of thyroid,Blood N
disorder?
15 Have you ever suffered from: Epilepsy, Any nervous disorder or mental condition, Paralysis or multiple sclerosis, Depression N
or psychiatric disorder,Cancer or a tumor.
16 Do you have any physical disability which is affecting your day to day activities? N
17 Are you currently suffering from any illness, impairment or taking any medication or pills or drugs? N
18 Have you ever been tested positive for HIV/ AIDS or Hepatitis B or C, or have you been tested/ treated for other sexually N
transmitted disease or are you awaiting the results of such a test?
19 Do you have/ had any recurrent medical condition or physical disability or illness or injury that has kept you from working for N
more than one week in last 5 years?
20 During last 5 years have you undergone or been recommended to undergo hospitalisation? N
21 During last 5 years have you undergone or been recommended to undergo operation? N
22 During last 5 years have you undergone or been recommended to undergo X-ray any other investigation (excluding check-ups N
for employment/ insurance/ foreign visit)?
23 State the name, address, and telephone number of your usual doctor who attends you in the event of illness, or if you have Not specific
been consulting with this doctor for less than three months, the name and contact details of your previous doctor.
24 We may require you to undergo medical examinations/tests. Some of the medical tests may require you to observe fasting. Residence
Please indicate your preference of location, near which the medical tests can be conducted.
25 What is your height? 5ft 4ins = 163cms
26 What is your weight (in kg)? 66
27 Do you consume alcohol? N
28 Do you use tobacco products? N
29 Are you currently consuming or have you ever consumed narcotics or any such other substance whether prescribed or not? N
30 Are any of your family members suffering from / have suffered from / have died of Heart Disease or High Blood Pressure or N
Stroke or Diabetes or Kidney disease or Cancer or HIV/AIDS?
31 Have you ever suffered or been diagnosed or been treated for Dengue or Swine Flu or Encephalitis ? N
Signature of Primary Life Assured
1. Have you submitted any simultaneous applications for life insurance at any of our offices or to another life insurance company, which is still pending OR are No
you likely to revive lapsed policies?
Name of the Sum Assured Types of Purpose of Proposed To be revived
company/ies payable on products cover
death (INR)
2. Please provide the details of any existing insurance cover of premium paying and/or paid up policies accepted at standard rate excluding group term insurance No
plan taken by your employer. (Also provide the details of any such proposals on your life / application for instatement ever accepted with extra premium, accepted
on other special terms, postponed, declined or withdrawn by self)
Policy / Company Year of Basic Sum Annual Base Medical Inforce /
Proposal Name Issue / Assured Premium Plan / Policy Lapsed*
No. Application (INR) (INR) Rider
Decision
Nominee Details (To be filled only if Proposer and Life to be assured are same)
Nominee Full Name Date of Birth(DD/ Gender(M/F/Tg) Relationship Contact No % Share
MM/YYYY) with Life to be
Assured
1 Mrs. GEETA DEVI 01/01/1974 Female Mother 100
1. Objective of Protection
Insurance:
2. Frequency:(for regular / Annual
limited premium paying plan)
11. For unit linked plans, kindly indicate % of allocation in below mentioned funds as applicable (please check the fund for the product applied)
Income Balanced Blue chip Opportuni Equity Diversified Bond Conservat Liquid Discovery Equity Bond Plus Secure Sustaina Total
Fund Fund Fund ties Fund Plus Fund Equity Fund ive Fund Fund Fund Advantage Fund Advantage ble Equity
Fund Fund Fund Fund
% % % % % % % % % % % % % % 100%
Declaration: 1. In case of non credit to my bank account with/without assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete / incorrect information, I would not hold HDFC Life Insurance Co. Ltd
responsible. 2. In case of NRI/NRE account, cheque will be issued.
Note: Please provide a cancelled copy of your cheque.
Signature of Proposer
Signature/Thumb impression of (Primary) life to be assured. Signature should match with signature on ECS/SI mandate
Date: Place:
Mobile:
Declaration (If signed in Vernacular language / Thumb impression has been affixed above)
Declaration to be made by a 3rd person where: The life(s) to be assured/proposed policyholder has/have affixed his/her thumb impression; OR the life(s) to be assured/
proposed policyholder has signed in vernacular; OR the life to be assured/proposed policyholder has not filled the application OR/AND The spouse of the life to be
assured/proposed policyholder has affixed his/her thumb impression or signed in vernacular the Declaration of Good Health applicable under Elite Option of Smart
Woman Plan.
I hereby declare that I have explained the contents of this application form to the life(s) to be assured / proposed policyholder in ________________________language and have
truthfully recorded the answers provided to me. I further declare that the life(s) to be assured/proposed policyholder has signed/affixed his/ her thumb impression in my presence.
____________________________________________________________________________________________________ ___________________________________
Name and address of Declarant Signature of Declarant
Occupation of the Declarant
Name and address of Witness Signature of Witness
Occupation of the Witness
_____________________________________________________________________ ______________________________________
Signature/Thumb impression of life to be assured/proposed policyholder Name, Designation & Occupation
Section 41 - Prohibition of rebates: 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 45 - 1.No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy, i.e., from the date of
issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later. 2. A policy of life insurance may be
called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud: Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or
assignees of the insured the grounds and materials on which such decision is based. 3.Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life
insurance policy on the ground of fraud if the insured can prove that the misstatement of or suppression of a material fact was true to the best of his knowledge and belief or that there
was no deliberate intention to suppress the fact or that such mis-statement of or suppression of a material fact are within the knowledge of the insurer: Provided that in case of fraud,
the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive. 4.A policy of life insurance may be called in question at any time within three years from the date
of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground that any
statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of which the policy was
issued or revived or rider issued: Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the
grounds and materials on which such decision to repudiate the policy of life insurance is based: Provided further that in case of repudiation of the policy on the ground of misstatement
or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal representatives
or nominees or assignees of the insured within a period of ninety days from the date of such repudiation. 5. Nothing in this section shall prevent the insurer from calling for proof of age
at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the
life insured was incorrectly stated in the proposal.