IRDA Registration No.

133

Corporate Office: 001 Trade Plaza, 414 Veer Application No.

Savarkar Marg, Prabhadevi, Mumbai 400025
In this policy, the investment risk portfolio is borne by the policyholder
Policy No.
FUTURE GUARANTEE ULIP
To be filled by Office :
Name of the Contract Major Life HUF Housewife
Inward No. Date of Inward Deposit Receipt No. Deposit Receipt Date
Branch /Unit Code: Product Name: Future Guarantee ULIP Please affix
Intermediary Type Passport size
Agent Broker Mall Assurance 3 Corporate Agent Direct Photograph
Agent Code : UM/LG Code :

Instruction for Filling this Proposal Form:

1. This form is to be filled in BLOCK LETTERS by the Proposer or by a person authorized by him. In case the Proposer is unable to fill in this form or the form is filled and/or signed in vernacular /
has a thumb impression put, then the Declaration printed at the end of this form must be filled and signed by an ENGLISH – knowing declaration. 2. Please answer all questions. Please tick box
thus (3) wherever appropriate. If any of the questions are not applicable, please write ‘N.A.’ Strokes/ Dots/ Dashes/ leaving the answer unanswered may lead to the rejection of the proposal.
3. The proposer must authenticate by signing any cancellation or alteration made in this form. 4. The process is advised to avail the facility of nomination, available in the form (Please Refer Q4).
5. Insurance is a contract of utmost good faith, which requires all the material facts to be disclosed to the insurer. In case of any doubt as to whether a fact is material or not , the fact should be
disclosed & kindly note that all amounts mentioned in this form are in Indian Rupees only.

1. LIFE to be Insured (To be filled in BLOCK LETTERS only) 2. PROPOSER (if not the LIFE to be Insured)
Title Mr. Mrs. Ms. Title Mr. Mrs. Ms.

First Name First Name

Middle Name Middle Name
Surname Surname

Date of Birth D D M M Y Y Y Y Date of Birth D D M M Y Y Y Y

Gender Male Female Gender Male Female
Nationality Indian NRI (Country of Residence) Nationality Indian NRI (Country of Residence)

Qualifications SSLC Under Grad Grad
Post Grad. Others ___________
Occupation Business Service Professional
Retired Student Agriculturist
Housewife Driver Armed Forces/ Police
Other ___________
Annual Income Rs.__________________________
Permanent Account No. (PAN)
Qualifications SSLC Under Grad Grad
Post Grad. Others ___________
Occupation Business Service Professional
Retired Student Agriculturist
Housewife Driver Armed Forces/ Police
Other ___________
Annual Income Rs.__________________________
Permanent Account No. (PAN)

Relationship with Life to be Insured

Marital Status Single Married Widow Divorced
Do you have an existing insurance policy : Yes No
Do you have an existing policy of FGLI : Yes No
If yes, please quote policy Do you have an existing policy of FGLi : Yes No
number (any one) If Yes, please quote policy number (any one)

3. Address for Communication with Proposer

i) Name & Address of Employer (if any):
Address
ii) Specify the exact nature of your duties:
iii) Are you exposed to any special hazard associated with your occupation (e.g.
chemical factory, mines, explosives, corrosives, etc.) which may render you
Landmark susceptible to injuries or illnesses? Yes No
City If Yes, please give details
State Age Proof: Voter’s I.D. Card Employer’s Cert
Pincode (Attach a self Driv License School/College Cert
attested copy) Birth Cert Baptism Cert
Tel No. Residence : STD :
PAN Card Domicile Cert
Res./Mob : STD :
Passport Gram Panchayat Cert
Others (Pls Specify _____)
E-Mail Address:
Residential Proof: Telephone Bill Ration Card
4. Nominee Details ( If Life Assured & Proposer are same) (Attach a self Electricity Bill Bank A/C Statement
Name attested copy) Letter from Recognized Public Authority
Others (pls specify)_____________
Date of Birth D D M M Y Y Y Y
Income Proof : I.T. Return/Assessment Order Employer’s Cert
Relationship with Life Assured: (Attach a self Others ___________________ (Give Details)
Address attested copy)
Rural (Population less than 5000) Non Rural
5. Appointee (in case Nominee is Minor) Driving Licence
Identity Proof: Passport
Name (Attach a self PAN Card Voter’s Identity Card
attested copy) Letter from Recognized Public Authority or Public Servant
Date of Birth D D M M Y Y Y Y
verifying the identity & residence
Relationship with Life Assured: Signature Others ______________________
Address
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 6. DETAILS OF THE INSURANCE COVER PROPOSED:

Fund Composition Percentage (%)

Sum Assured : Rs ____________________________/- Future Secure (max 25%)
Future Income
Annualized Premium : Rs.___________________________/-
Future Balance
Policy Term (Also Premium Paying Term) ___________________ yrs. Future Apex
Total

7. Payment Details

Premium Amount : Rs______________________/-

Payment Remitted by Cash Cheque Demand Draft Credit Card ECS / SI
Frequency of Payment Yearly
Cheque / DD drawn on Bank
Branch Address
Cheque No./DD No.
Credit /Debit Card No.

Credit Card/ Debit Card Transaction No.

D D M M Y Y Y Y
Expiry Date:
Method of Renewal Cash Cheque Salary Deduction Credit Card ECS / SI (Attach Authorization Letter)
Premium Payment
Bank Account Detail for receiving payment from Future Generali India Life Insurance Co. Ltd :
Account No. (Proposer)
Bank Name
Branch MICR Code

8.1 PERSONAL HEALTH RECORD OF LIFE TO BE ASSURED: (To Be Filled Only For “With Life Cover” Option)
Height : Cms Weight : Kg
In the past 6 months, has your body weight changed by more than 5 Kg? Yes No
If yes, please mention whether lost or gained and how many Kgs. Lost ; Gained ; Amount ____________ Kgs
Please state Cause of a change in weight_________________________________________________________________________________________________________________
Visible identification mark if any______________________________________________________________________________________________________________________
8.2 Health details of life to be assured

Answer the following as Yes or No Yes No

A. Are you suffering from or have you ever suffered from or sought advice or treatment or have been advised to undergo investigation or
treatment for: ( Pl tick the relevant description)
i. Ulcer, Colitis, Gall Stones, Chronic Diarrhea, Piles, Fistula, Hepatitis A/B/C, Jaundice, Cirrhosis, or other Liver or Pancreas or Digestive Disorders?

ii. Chest Pain, Palpitation, Rheumatic Fever, Stroke, Heart Attack, Heart Murmur, Shortness of Breath, or other Heart Disorders?

iii. Asthma, Bronchitis, Chronic Cough, Pneumonia, T.B., or any other respiratory or lung disorders?

iv. Any skin disorder (e.g. dermatitis, eczema, Leprosy or psoriasis)?

v. Cancer, Tumor, Enlarged Glands or Enlarged Lymph Nodes?

vi. Thyroid Disorders or any other hormonal disorders?

vii. Anemia, Bleeding, hemophilia, thalassemia or Blood Disorders?

viii. Dizzy / Fainting Spells, Epilepsy, Multiple Sclerosis, Tremors, Numbness, Double Vision, Insomnia, Depression, Stress related problems, Paralysis,
Nervous or Mental / Emotional Disorders?
ix. Urine, Kidney, Bladder, Reproductive Organ, Hydrocele or Prostrate Disorders?

x. Arthritis, Gout, Hernia, Joint Pain, Muscle, Bone Fracture or disorders?

xi. Disorders of the Eyes, Ears, Nose & Throat?

xii. High / Low Blood Pressure?

xiii. Diabetes or sugar in the urine?

xiv. Congenital or Hereditary disorders or diseases?

xv. Alcohol or Drug abuse or dependency?

B. Apart from the medical conditions mentioned above, have you in last five years

i) Suffered from any ailment / injury requiring treatment for more than a week?

ii) Undergone or are currently undergoing or advised to undergo any form of medical treatment, investigation or test?

iii) Consulted any doctor or other health practitioner except for common cold/influenza lasting less than 7 days ?

iv) Ever remained absent from your place of work on medical grounds for 7 consecutive days or more ?

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 C. Have you ever or are you currently suffering from any defect in sight, hearing or speech, or any physical impairment or disability or abnormality?

D. Have you or your spouse received medical advise, testing or treatment in connection with sexually transmitted disease or HIV infection, or suffered
from prolonged weight loss, Diarrhoea, enlarged glands or have been advised to abstain from donating blood?
E. Do you have any health symptoms or complaints for which a physician/ homeopath/ ayurvedic /alternative medical advisor has been consulted
or treatment received e.g. persistent fever, unexplained weight loss, loss of appetite, pain, swelling etc.?

If you have answered YES to any part of Question 8.2, please complete the table below & attach relevant questionnaire:
Illness, Injury or tests Date Commenced Type of treatment Duration of Illness/ Date of last symptoms Current Condition Full name and address of doctor
injury or hospital (if any)

In case of major sickness/operation, the special questionnaire, hospital/ doctor’s report has to be submitted.

Section 41 of the insurance act, 1938 : (1) No person shall allow or offer to allow either
directly or indirectly, as an inducement to any person to take or renew or continue an
insurance in respect of any kind of risk relating to lives or property in India, any rebate
of the whole or part of the commission payable or any rebate of the premium shown on
the policy, nor shall any person taking out of renewing or continuing a policy accept any
rebate, except such rebate as may be allowed in accordance wit the published prospec-
tuses or table of the insurer.
Provided that acceptance by an insurance agent of commission in connection with a
policy of life insurance taken out by himself on his own life shall not be deemed to be
acceptance of a rebate of premium within the meaning of this sub-section if at the time
of such acceptance the insurance agent satisfiets the prescribed conditions establishing
that he is a bona fide insurance agent employed by the insurer. (2) Any person making
default in complying with the provisions of this section shall be punishable with fine
which may extend to five hundred rupees.
Section 45 of the Insurance Act, 1938 : “No policy of the life insurance effected before
the commencement of this act shall after the expiry of two years from the date of com-
mencement of this act and no policy of life insurance effected after the coming into
force of this act shall, after the expiry of two years from the date on which it was effected,
be called in question by an insurer on the ground that a statement made in the proposal
for insurance or in any report of a medical officer, or referee, or friend of the insurer, or in
any other document leading to the issue of the policy, was inaccurate of false, unless the
insurer shows that such statements was on a material matter or suppressed facts which
it was material to disclose and that it was fraudulently made by the policy-holder and
that the policy holder knew at the time of making it that the statement was false or that
it suppressed facts which it was material to disclose;
Provided that nothing in this section shall prevent the insurer from calling for proof of
age at any time if he is entitled to do so, and no policy shall be deemed to be called in
question merely because the terms of the policy are adjusted on subsequent proof that
the age of the life insured was incorrectly state in the proposal”

Declaration by Life to be Insured Declaration for signing in Vernacular

I understand and agree that the statements in the proposal will be the basis of the contract be-
tween me and Future Generali Life Insurance Co. Ltd. [“The Company”] and that if any statement
is untrue or inaccurate or if any of the matter material to this proposal are not disclosed the com-
pany may void the contract and all the premium paid will be forfeited to the company. I agree
that I will inform the company if between the date of the proposal and the date of the issue of
the policy • there is any change in my general health occupation or financial position • any other
proposal or application to any other insurance company on my life is declined/postponed or ac-
cepted other than standard terms so that the company may consider the terms of acceptance. I
understand that if I fail to do so then the company may void the contract and all the premiums
paid will be forfeited to the company.
Future Generali Life Insurance Co. Ltd. requires that this proposal is completed by the proposer. If
proposer does not read, write / speak English then this proposal may be completed by another
person, then such person need to complete this declaration. I have explained the contents of this
proposal to the proposer and endeavoured to ensure that the contents have been fully under-
stood. I have accurately recorded the responses to the information sought by the proposal form
and I have read the responses back to the Proposer and confirmed that they are correct.
Name of the Declarant :
Address

Signature / Thumb Impression of the Proposer Signature/ Thumb Impression of Life to

be assured if other than the proposer

Date: D D M M Y Y Y Y
Signature of the Declarant
The content of this proposal and documents have been fully explained to me and I have fully
Signature of the Witness Proposer’s Mobile/Telephone Number
understood the significance of the proposed contract
Name of witness
Address
Place Date

Confidential Report (To be completed by the Advisor after receiving the complete proposal form) Signature of the Life to be Insured Signature of the Proposer
I hereby declare that the proposal form has been completely understood by the client and facts
Name of Witness
disclosed therein are true and correct to the best of my knowledge and belief. I am satisfied with
the identity of this client and recommend proposal for acceptance
(if different of the Life to be Insured)

Place Place

Date: D D M M Y Y Y Y Date: D D M M Y Y Y Y
Signature of advisor Signature of Sales Manager