PROPOSAL FORM

Single Life Traditional Plans Full Underwriting

* The entire form is to be filled in black ink only. Use CAPITAL letters for information required in boxes with a space between words. Use separate proposal forms for
each plan. Any cancellation/alteration is to be signed by the proposed policyholder or life to be assured as appropriate.
* All relevant supporting documents are to be provided. Nomination should be done when proposal is on own life.
* All information provided here shall be relied on and should be accurate, complete and true in all respects for processing the proposal quickly. In case you have any
doubt whether the particular information is material or not, please disclose the information.
* Where the proposed policyholder has not filled up the application form or where he/she has affixed the thumb impression, the corresponding declarations are to be
completed.
* Section B (questions 8, 10, 12, 14 & 15) and Section C (questions 2 and 3) are mandatory only where the life to be assured and the proposed policyholder are the
same. Details on Demat account & UID , Email, Pin code and Contact numbers are mandatory. Contact details mentioned herein will be used for future
communication.
* The plans mentioned in this proposal form have been approved by IRDA (Insurance Regulatory and Development Authority) and have been allotted an Unique
Identification Number (UIN). This number is available in our sales literature and also on IRDAs website for verification.

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

FOR OFFICE USE ONLY *

Consultant Name & Code:

License No:
Company Lead:
IA/CAO Emp No**
Channel code
Branch code:

License Expiry Date

Simultaneous Proposals:

No

Bancassurance Code:

Lead Reference No:

Channel Partner Customer ID:

IA/CAO Name:
FOS code:
Tele code:

Yes
No of Proposals sent together:
Credit Card
Cash
Payment Details:
Yes
Consolidated Payment:

Cheque

No

To be filled by the Branch Operations Officer:

Verified by BDM / CAM:

DD

Form:

Yes

Signature of FC:

Name / Signature of BDM / CAM

No

Yes

No

Branch Ops Checklist

Page

Count

Particulars

Pan card

Received at

Age Proof

Branch Code & Branch on:

ID proof

Receipt No:
Client ID:

Address Proof
CCR

No of Simultaneous Proposals:

Income Proof

Pan Card
Bank Account/Bank Pass book Statement (Showing
transactions within last 6 months)

Bank Statement/Passbook (showing salary credit of last 3

months)

Questionnaire / Addendum
Address Verified (Mailing & Permanent)

Yes

No

Yes

No

ECS Mandate with cross cheque

Yes

No

Scrutiny done by:

SI Mandate

Yes

No

Comments:

Existing customer-details checked with prev policy

Product Code:

CPP

Is PPH/LA an Employee:

No

To be filled in by Certified Financial Consultant **IA / CAO Insurance Associate / Corporate Agency Officer

SECTION A PLAN DETAILS

Please Note: You are requested to study thoroughly and indicate the type of plan and additional benefits that you propose to
take. Please choose from Plan Selection Instruction Sheet For each plan, separate proposal forms have to be filled in.
Plan Names

Frequency

Additional Benefits (Riders)

ClassicAssure Plus

Annual, Half yearly , Quarterly &

Monthly

No Additional Benefit currently available

Super Savings Plan

Sanchay
Super Income Plan
YoungStar Udaan
Click 2 Protect Plus
Others (Please Specify)

Kindly submit completely filled Juvenile questionnaire if the age of Life to be assured is less than 12 years.
Subject to our prevailing operational rules, it may be required for Monthly Frequency to be taken with ECS/SI & and to pay first 3 months premium in advance along with the Proposal Form.

Please update the desired plan and additional benefits in the below table:
S.No.
1

Plan Name (A)

Main benefit Sum Assured (Rs.)

Main benefit premium (Rs.)

30000000.00

Life Option
Additional benefit(s) (if any) (B)

32312.00

Additional benefit Sum Assured (Rs.)

Additional benefit premium (Rs.)

A
B
Total Premium including taxes (A+B)
For YoungStar Udaan, Select

32312.00

the Benefit Option and Plan Option

Benefit Option
Plan Option
Life
For Click 2 Protect Plus, Selected Plan Option
Policy Term (Yrs): 40
Premium Payment Term (for plans other then Super Income)
Benefit Term:
For Super Income Plan -

40

40

(Applicable if Benefit Term is less that Policy Term for Click2Protect Plus with Income Benefit Option)

Select

Frequency of Premium Payment:

the Policy Term (PT), Premium Payment Term (PPT) & Payout Period (PP)

Options

PPT(Yrs)

PP(Yrs)

PT(Yrs)

Options

PPT(Yrs)

PP(Yrs)

PT(Yrs)

Option 1

16

Option 4

10

12

22

Option 2

10

18

Option 5

12

12

24

Option 3

10

10

20

Option 6

12

15

27

Commencement date:

Annual

Backdating Charges (Rs):

(If applicable)

(DD/MM/YYYY) (Has to be within the same financial year for backdated cases)

Payment Details:
CREDIT_CARD
Drawn on (Bank name):
Bank Account Number

Amount:
Date:

Cheque/DD No:

32312.00
18-Oct-2014

In case the life to be assured is the guardian of a disabled person, is this insurance policy being taken primarily to protect the disabled person?
UID Number:

Do you want the policy in Demat form?

If yes, e insurance account number

If a policy is requested in demat format, it will not be given in physical form. If policy is
given in physical format, it will not be given in demat form.
SECTION B PERSONAL DETAILS OF LIFE TO BE ASSURED
1. Title:

MR

Client Code (Office use only)

First Name:

Madhuresh

Middle Name:
Last Name:

Agrawal

Maiden Name:
(Only for married females)

Fathers / Spouses Name:

Ankita Gupta

Employee of HDFC Life:

No

If Yes, Employee Code & Location

7th Floor, Tower D, Unitech Cyber

Proposer/policy holder other than individual please mention 'Legal name' in the Name column

2. Date of Birth (DD/MM/YYYY)

3. Gender
Male

19-Oct-1985
6. Nature of Age Proof attached:

Pan card

4. Marital Status
Married

5. Nationality
Indian

7. Educational Qualification:

PGR

8. Are you a Non Resident Indian (NRI)?

9. Visible Identification Mark:

NO

If yes, name of resident country and attach NRI questionnaire

Applied For

10.PAN: AMSPA2689K

11. Aadhar card number:

Not Applicable

PAN is mandatory for all applications where as on date of application, the cumulative amount of Premium and/ or
Single premium Top-up is equal to or exceed Rs 50000 in an financial year for a proposer.

12. Place of Birth:

13. If you are our existing life assured, assignee, nominee, proposers kindly enter Policy No(s):
Pan Card

14. Proof of Identity

Name of Issuing Authority:

Serial No:

Date of Issue of Document:

15. Proof of Address(must for both correspondence & permanent)

Bank Account/Bank Pass book Statement (Showing transactions within last 6 months)

If address proof provided other than of self / spouse / father, then please specify the name of owner of residence

16. Where would you like to receive all your communication?

You like to receive communication by

SMS

Email

Office

Residence
Tele Calls

Permanent

Mail

Preferred Language of Communication

17. Correspondence Address:
House / Flat No:

Villa No 12 Tatvam Villas

Street / Area:

Sector 48

Landmark:

Sohna Road

City/District:

Gurgaon

State:

Pin Code:

122001

Haryana

18. Permanent Address: (If different from correspondence address)

House / Flat No:
Street / Area:

Villa No 12 Tatvam Villas

Sector 48

Landmark:
City/District:
State:

Pin Code:

Gurgaon
Haryana

Mobile:
9971740123
Telephone No (O):
E-mail Address:
madhurag123@gmail.com

122001

Telephone No (R):
Fax No:

124-4949620

SECTION C PERSONAL AND FAMILY HISTORY HISTORY OF LIFE TO BE ASSURED

1. Sources of Funds If Premium, wherever relevant is equal to or more than Rs. 1 Lakh, please enclose proof of income e.g. ITR
Salaries

Business

100

House Property
0

2. Are you a Politically Exposed Person?

Capital Gains
0

Investments
0

Agriculture
0

Others

Total

100%

NO

Definition of a Politically Exposed Person: Politically exposed persons are individuals who are or have been entrusted with prominent public functions in a foreign
country, their family members and close relatives such as Heads of States or of Governments, Senior politicians, Senior government/judicial/ military officers, Senior
executives of state-owned corporations, Important political party officials, etc

3. Present Occupation Details:

Salaried
Designation:
Algorithmic Trader
Gross Yearly Income from all Sources (Rs):
3500000.00
Office Address
Tower Research Capital India Pvt Ltd
7th Floor, Tower D, Unitech Cyber Park, Sector 39, Gurgaon

*HOUSEWIFE kindly submit Housewife Addendum 9 STUDENTS kindly state 1. The course being pursued 2. Name and address of college/institution (excluding coaching classes) 3.
Duration of the course 4. Year/semester/standard Address of present employer or business premises if self employed and address of registered office/main place of business in case of other
entities) 10 Proposer/policy owner is other than individual please mention Designation & fill Legal Form11Address of present employer or business premises if self employed and address of
registered office/main place of business in case of other entities

The exact nature of work performed by you (e.g. Clerical, mechanical, supervisory job, etc.)

Writing computer programs for automated

Please provide details, if any, regarding your occupation or business, which may render you
susceptible to injury or illness. (e.g. exposure to chemical substances/hazardous materials/
harmful dust or gases/ explosives/ working at heights/ handling heavy machinery etc.)

No

Industry to which your company or business belongs (cement, banking etc.)

Finance

4. Do you take part in any hobbies/activities that could be considered dangerous in any way?
e.g. aviation (other than as a fare-paying passenger),mountaineering, deep sea diving or any form of racing

No

If Yes, please provide details

5. Have you resided overseas for more than 6 months continuously during the last five years, or are you having plans at present to do
so in the next 6 months?
Yes
If you have answered yes to the question, please give the names of the countries and duration of stay:
Yes / No
Past Overseas Travel

Yes

Future Overseas Travel

No

Name of Countries

Duration

United States

Months

24

Months

6. Do you have any existing insurance cover of premium paying and/or paid up policies (excluding group term insurance plan taken by
your employer)?
No
If yes please fill details below
(i)Sum Assured payable on
death

(ii) Sum Assured

payable on
accidental death
(excluding i)

(iii)Benefits on
disability /critical
illness

How much of this cover

(i+ii+iii) was taken in last 1
year

How much cover (i) is taken

during last 5 year?

7. Have you submitted any simultaneous applications for life insurance at any of our offices or to another life insurance company,
No
which is still pending OR are you likely to revive lapsed policies?
Name of the company/ies

Sum Assured
payable on
death

Type of Products

Purpose Of cover

Proposed / To be revived

8. Has any application for insurance on your life been:

Postponed
No

Accepted with extra Accepted on other

premium
special terms

Declined

No

No

No

Withdrawn by self
No

Name of the
company/ies
Policy Number
Reason
9. Height

Cms (or)

5 Feet

Inches

10. Weight

69

Kgs.

11. Are you currently consuming or have you ever consumed any of the following:
Substance Consumed

Yes

No

Consumed As

Quantity

a. Alcohol

No

Beer (1 unit = 330 ml):

Spirits (1 unit = 30 ml):

NA

b. Tobacco

No

Cigarette ( no. of unit ):

NA

Bidi ( no. of unit ):

c. Narcotics (12)
(for example ganja,hashish,heroin,
cocaine,charas,marijuana,etc.)

No

NA

Wine (1 unit = 125 ml):

NA

Cigar ( no. of unit ):

NA

NA

Chewing tobacco(in gms):

NA

(10) 1 unit equivalent to 330 ml of beer / 125 ml of wine/30 ml of spirits (11) 1 unit equivalent to 1 cigar/1cigarette/1 bidi. If chewing tobacco please specify how many grams per day.

NA

12. State the name and address of your usual doctor who attends you in the event of illness, OR if you have been consulting with this
doctor for less than 3 months, the name and address of your previous doctor.
Name:
House / Flat No:
Street / Area:

N/A
Pin Code:

City/District:
State:
Telephone No

Mobile:

Email:
13. Personal medical details:

(If answered Yes in sub-question I please fill the relevant questionnaire)

Ia. Have you EVER suffered from any of

the following conditions?

Yes

No

Questionnaire

Ib. Have you EVER suffered from any of Yes

the following conditions?

(a) Diabetes

No

(k) Stroke

No

(b) High blood pressure

No

(l) Liver disorder

No

(c) Respiratory disorders

No

(m) Kidney disorder

No

(d) Epilepsy

No

(n) Disorder of the digestive system

No

(e) Back problems

No

(o) Paralysis or multiple sclerosis

No

(f) Arthritis

No

(p) Blood disorder

No

(g) Any nervous disorder or mental

condition

No

(q) Heart Disease

(h) Abnormality of thyroid

No

(r) Any recurrent medical condition

/disability (including eye/ear disorder)?

No

(i) Tuberculosis

No

(s) Cancer or a tumour

No

(j) Depression or psychiatric disorder

No

II. Do you have any physical disability?

III. Are you currently suffering from any illness, impairment, or taking any medication or pills or drugs?
IV. Have you ever tested positive for HIV/AIDS or Hepatitis B or C, or have you been tested/treated for other sexually
transmitted diseases or are you awaiting the results of such a test?
V. Do you have / had any recurrent medical condition or physical disability or deformity or illness or injury that has kept
you from working for more than one week in the last 5 years?
VI. During the last 5 years, have you undergone or been recommended to undergo:
a. Hospitalisation?
b. An operation?
c. X ray or any other investigation (excluding check-ups for employment/insurance/foreign visit)?

No

No

No
No
No
No
No
No
No

If you have answered ''Yes'' to any of the sub questions [I (a to s), II, III, IV, V and VI] asked under question 13 of this section, please answer the
following
Nature of Illness/Accident

Date of
Diagnosis
/Event

Name and Address of

the Doctor

Details of Investigations
Done

Under
Medication
(Yes/No)

Fully
recovered
(Yes/No)

14. To be answered by the female life to be assured:

Please tick the appropriate answer to all of the questions below.

Question (a) to (c) to be answered by female life to be assured below age 45 yrs only
(a) Are you presently pregnant?
(b) If Yes, how many weeks? Kindly attach the Pregnancy Questionnaire
(c) Have you ever had any disease of uterus, cervix, or ovaries?
(d) Have you ever undergone hysterectomy?*
* Please attach hysterectomy questionnaire and histopathology reports if answered as Yes
15. We may require you to undergo medical examinations/tests. Some of the medical tests may require you to observe fasting. Please indicate
your preference of location, near which the medical tests can be conducted.
Residence

Workplace

16. Family history of the life to be assured.

Have any of your parents, brothers or sisters died or suffered prior to the age of 65 years from:

Yes

Heart disease, high blood pressure, stroke, diabetes, kidney disease, cancer?
If you have answered Yes to any of the questions above, please give details:
Relation to the life to
be assured
Father

Disease
Heart disease

Age of Diagnosis
48

Alive/Deceased

Alive

Current Age/Age at
death
59

Any form of paralysis, any hereditary disorder (such as Huntingtons disease, Polycystic disease of the kidney or familial polyposis of the
colon)
No
If you have answered Yes to any of the questions above, please give details:
Relation to the life to
be assured

Disease

Age of Diagnosis

Alive/Deceased

Current Age/Age at
death

SECTION D (I) - PERSONAL DETAILS OF NOMINEE / BENEFICIARY / PROPOSED POLICYHOLDER

Nomination facility is available only when the proposed policyholder is taking a policy on his/her own life. Hence if you are proposing to apply on
your OWN life please use this section to furnish the personal details of the nominee else please use this section to fill in your personal details.
Nominee is the person to whom the money secured by the policy shall be paid in the event of death of the life to be assured. The beneficiary to be
the sole person entitled to the benefits and payments (except any refund payable on cancellation in the free-look period) under the policy. In any
event where the benefits revert to the life to be assured under the provisions of the policy and the life to be assured does not intend to appoint any
other beneficiary under the policy, the life to be assured can at that time appoint a nominee to receive the proceeds of the policy and give a valid
discharge to the Insurance Company
Note: It is advisable to appoint nearest blood relative as nominee / beneficiary.
Mandatory: Please also fill in the KYC form if you have selected proposed policyholder
Please tick relevant box :
Title:

Nominee

MRS

First Name:

Beneficiary

Gender:

Proposed Policyholder

Female

Client Code (Office use only):

Date of Birth:

06-Dec-1988

Ankita

Middle Name:
Last Name:

Gupta

Relationship of nominee / beneficiary/proposed policyholder to life to be

Correspondence Address:

Wife

Same as stated on page 3, if different then please fill the fields below

House / Flat No:

Villa No 12 Tatvam Villas

Street / Area:

Sector 48

City:

Gurgaon

Pin Code:

122001

State/District:

Haryana

Mobile:

9910528877

Telephone No. (R):

0124-4949620

E-mail Address:

ankitag612@gmail.com

Telephone No. (O):

SECTION D (II) APPOINTEE DETAILS (To be filled only if nominee/beneficiary is minor.

The Appointee should be a major as on date of this application and must not be life to be assured)
Title:

Gender:

Client Code (Office use only):

First Name:
Middle Name:
Last Name:
Date of Birth:
Relationship to the nominee / beneficiary:
Correspondence Address

Same as stated on page 3, if different then please fill the fields below

House / Flat No:

Street / Area:
City:

Pin Code:

City/District:

Mobile:

Telephone No. (R):

E-mail Address:
Signature of appointee accepting the appointment:
(appointee cannot affix thumb impression)

Telephone No. (O):

SECTION E - DECLARATIONS
Declaration of the Life to be Assured and Proposed Policyholder:
I understand, agree and declare that - I have read and understood the product and the content of the proposal form. I have read the entire text, features, disclosures
and terms and conditions while applying for this policy. That the response to questions in this Proposal Form (also application) and all the information given by me
or on my behalf or in respect of the life to be assured (LA) in this application is true and I have not withheld or suppressed any material fact within my knowledge. I
consent that information provided by me including sensitive personal information (collectively "data") can be used / processed by HDFC Standard Life Insurance
Company Ltd. ("the Company") and its authorised associates, agents and service providers for the purpose of providing insurance services / products to LA and
transactions under the same . I consent to the Company seeking medical information from any doctor who at any time has attended LA regarding LA's physical or
mental health or seeking information from any other insurance company to which LA has applied for insurance. In the event of LA being medically examined, the
answers given to the medical examiner acting on behalf of the Company shall be deemed to be incorporated in this application. That these statements, and any
information or documents sought by the Company from any person authorized by me to provide such information, all declarations, affidavits and other statements
made by me and relied upon by the Company to assess the risk on LA under this application shall form the basis of the contract of insurance between myself and the
Company and shall be the basis of assessment, assumption and acceptance of risk by the Company. If any statement/information made/given by LA to you or to any
other person in connection with this application are inaccurate or false, or are found to be inaccurate or false, or if there is any non disclosure, withholding or
suppression of any fact pertaining to me or my health condition, physical or mental, or pertaining to financial position, as at the time of application, the Company shall
have the right to vary the benefits under the insurance policy or cancel the policy immediately by paying the applicable surrender value. The Company has the
absolute right either to accept or reject a proposal without giving reasons thereof and I undertake that there shall be no costs, claims, charges that will be raised by me
against the Company. I undertake to notify the Company any changes in LAs health condition or financial condition between the date of this application and prior to
acceptance of the risk by the Company. I understand the significance of the contract of insurance and that the contract will be governed by the provisions of the
Insurance Act, 1938 and the Indian Contract Act, 1872, and that the same will not commence until written acceptance of this application by the Company is received
by me. That the premium payable as well as the sum assured (main as well as additional/ rider benefits) may vary upon assessment of risk by the Company. That the
Company shall be entitled to retain the premium paid along with this application as an interest free initial deposit to be adjusted against premium payable upon issue
of the Policy. In the event of the application not being accepted by the Company the aforesaid deposit shall be refunded without any interest subject to permissible
deductions. That any statutory levy, taxes or charges including any indirect tax may be charged to me either now or in future by the Company and I agree to pay the
same. I confirm that in respect of unit linked insurance policies I have received the sales illustration provided by the Company in the prescribed manner and that I have
read and understood the same and further understand and accept the investment rate and that the rates assumed therein are not guaranteed. All/any amounts
paid/payable towards this Policy will be out of legally declared and assessed sources. I agree that the Company can peruse my financial profile and it can cancel this
contract if I am found guilty under any laws directly/indirectly relating to anti money laundering. Amounts paid, otherwise than from my account shall be permitted only
if an insurable interest can be established. I will provide information required by the Company, on its own or under any lawful instruction/ order, regarding sources of
funds/utilization/withdrawals. I agree to any of the information provided in the application, annexures thereto and the results of medical tests, if any, being made
available by the Company to any statutory authority or reinsurer(s), as well as to any other person or entity for the purposes of assessing the application/processing
any claim arising under the Policy. I declare and agree to be bound by the contents of this application and the information provided herein. All documents submitted
by me/us along with this application are authentic, valid, and where relevant true copies of originals for purpose of this application

Signature/Thumb impression of Witness Name

& Address

Signature/Thumb impression of life to be assured Signature/Thumb impression of proposed policyholder

Signature should match with signature on ECS/SI (Only if different from life to be assured) Signature
mandate or bank records
should match with signature on ECS/SI mandate or
bank records
Date :

Occupation

Mobile:

18/10/2014

Place :

9971740123

Date :

18/10/2014

Place :

Mobile:

Above signature and mobile number will be used for all future interaction and verification. Please provide your in-use mobile no. and sign as per your bank records/identity proof
submitted 14 Witness Signature, Address and Occupation is mandatory along with signature of LA / Proposed Policy

DECLARATION FOR SPOUSE RIDER: To be filled only if the Spouse is Employed

Sum Assured: Rs. 10 Lakhs Name of Spouse _______________________________ Date of Birth_____________________ I declare to the best of my knowledge and belief that my spouse
is in good health and carrying on a normal life and has not been hospitalized for, required medication or treatment or consulted a physician in the last 5 years. Also, my spouse has never been
diagnosed with, treated for, or advised to seek treatment for heart disease, diabetes or raised blood sugar, high blood pressure, chronic kidney or liver disease, mental or nervous disorder,
cancer, lung disorder, physical deformity or HIV/AIDS.
I understand that if this declaration on my spouse's health is inaccurate or false, or is found to be inaccurate or false, or if there has been any non-disclosure, withholding or suppression of any
fact or information pertaining to my spouse's health condition, physical or mental, as at the time of application, the Company shall have the right to vary the benefits under the Policy/Rider or
treat the same as void forfeiting the benefits or repudiate the claim.
Date and Place
Signature of Life to be Assured
Note: 1. You may withdraw the consent till anytime before the proposal is logged into our systems. In that case, your proposal shall stand withdrawn by you. 2. The data provided by you and if
subsequently found to be inaccurate, can be rectified upon a written request by you and as per our process except such data which is the basis of this contract / policy unless agreed to by the
Company.

Note: 1.You may withdraw the consent till anytime before the proposal is logged into our systems. In that case, your proposal shall stand withdrawn by you. 2. The
data provided by you/LA and if subsequently found to be inaccurate, can be rectified upon a written request by you and as per our process except such data which
is the basis of this contract / policy unless agreed to by the Company.
Please contact us on any of the following touch points in case of non receipt of your HDFC Life policy document after 1month from date of application. Call us on
helpline number 18602679999 (do not pre fix any country code e.g. +91 or 00), SMS SERVICE to 5676727 for call back request or email us at
service@hdfclife.com.

Note: Please retain your copy of the acknowledgement slip for future references
Declaration to be made by a 3rd person where:
The proposed policyholder has affixed his/her thumb impression; OR
The proposed policyholder has signed in vernacular; OR
The proposed policyholder has not filled the application.
I hereby declare that I have explained the contents of this application form to proposed policyholder in____________________________________language and have
truthfully recorded the answers provided to me. I further declare that the proposed policyholder has signed/affixed his/ her thumb impression in my presence.

Name and address of Declarant

Signature

Declaration made by life to be assured/proposed policyholder

I hereby declare that the content of the form and document has been fully explained to me and I have fully understood the significance of the proposed contract.

Signature/Thumb impression of life to be assured/proposed policyholder

MANDATE FORM FOR DIRECT DEBIT

(Please use a separate request form for each policy)
To,
The Manager
I/We, the undersigned, hereby: {Tick whichever is applicable}

Date:

18/10/2014

Request for maintenance of standing instruction for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select banks only)
X Request to remit bill amount for premium payment to HDFC Standard Life Insurance Co. Ltd. through Electronic Clearing Service (for select
cities only).
Request for direct debit from my bank account (non ECS location) for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select
banks only*)
Preferred billing date:

(DD/MM) *

Policy No. :

Name of proposed policyholder:

Name of account holder (if different from above):
Premium amount to be debited: Rs.
Amount in words: Rs.
Bank A/c no (from where premium will be debited):
Bank name & address:
9 Digit MICR no. (not required for SI to HDFC Bank Ltd / Direct Debit from bank account of non ECS location):
Frequency (Please tick): Annual
Type of account: Saving
Account holder signature:
Date:
Place:
Proposed policyholder signature*:
Date:
Place:
(*If different from account
Relationship with account holder (If proposed policyholder is different from account holder):
Reason for payment (If proposed policyholder is different from account holder):
*Kindly check overleaf for the terms & conditions, Kindly submit this mandate 30 days prior to the premium due
(Please refer point 8 of the declaration)

For office use only

* Next premium due date:

Last premium due date:

Policy number

Account number of the beneficiary (with HDFC Bank Ltd):

---------------------------------------------------------------------------------------------------------------------------------CUSTOMER ACKNOWLEDGEMENT
Date:
Plan Name
Cheque / DD

Frequency of Payment
Amount (Rs.)

Term
Bank

Other requirements (LIST)

1.

2.

3.

I,
have collected the above documents and will be submitting it tothe nearest HDFC
Standard Life branch for further processing.
(Signature of Financial Consultant)
(Financial Consultant contact number)
Financial Consultant Code)
> This is NOT A PAYMENT RECEIPT but only a proof of the documents received from you. > All cheques/DD should be crossed and drawn in
favour of HDFCSLIC. > If payment is not made by way of Cheque/DD, Kindly make cash payment at an HDFC Standard Life branch and collect
your initial deposit receipt. > This acknowledgement does not in any way constitute acceptance or commencement of risk.
Easy Connect: If you have any queries or clarifications regarding your policy, kindly contact us at any of the following service touch points accessible from 9 am to
9 pm all 7 days, alternatively you may e-mail us at onlinequery@hdfclife.com
@ Call 1800 266 0315 tol free
SMS service to 5676727
Dear _______________, we acknowledge the receipt of your SI/ECS mandate and it will be processed within 30 days from today. After attaching the same in our system, we will forward it to your
bank for further processing. In case of rejection, the same would be communicated to you; or else it would mean that your mandate is lodged in successfully.
Effective the next due date the premium would be debited from your bank account. Thank you for choosing direct debit as your premium payment option.

Branch Stamp

Acknowledgement received
(Signature of the Customer)
Continued Overleaf

DECLARATIONS FOR DIRECT DEBIT

1. I/We undertake to keep sufficient funds in the funding account on the date of execution of standing instruction.
2. I/We hereby authorise the bank / Bill Junction to communicate my/our funding account number and any other account details (as may be
necessary) to HDFC Standard Life Insurance Company Ltd. for the specific purpose of recovering my/our HDFC Standard Life Insurance Company
Ltd. premium payments through a standing instruction of my/our account.
3. I/We hereby authorise HDFC Standard Life Insurance Company Ltd., in the instance of the Standing Instruction / ECS debit failing for any
reason, to authorise the bank / Bill Junction to recover the premium payable through a direct debit to my/out account with the mentioned bank.
4. I/We agree that for changing the premium amount as per my requirement, I/We will furnish a fresh mandate for such change in the premium
amount, which will supercede all other mandates previously given..
5. I/We agree that in the event of any violation by me/us of any undertaking confirmed in the agreement herein shall amount to an event of default
in the terms of the Insurance Policy and HDFC Standard Life shall be entitled to invoke the remedies available to it in terms of the policy
agreement.
6. I/We agree that in the event of the bank being unable to debit my account for want of sufficient funds or for any other reason, HDFC Standard
Life shall be entitled to deal with my policy in the manner as described in the policy provisions, unless the payment is received by any alternate
mode on or before the specified date.
7. I/We undertake to revoke the Standing Instruction in the event of the policy being withdrawn/surrendered/lapsed/terminated, where any
subsequent amount is debited to my account due to the reason that the SI not being revoked, I/We shall only be entitled to a refund of such amount
on my/our demand and no interest or compensation is payable on the same.
8. I/We agree that the premium will be debited starting from the premium due date / preferred billing date which occurs after the date of this
mandate, till the last premium due date unless the mandate is revoked.
a. I/We agree and understand that Preferred Billing Date should be within 30 days of the PTD and will always bebefore the PTD.
b. I/We agree that the premium will be debited on the Preferred Billing Date, if opted and this date will not be revised till the last premium due
date unless the mandate is revoked.
c. I/We agree and understand that in cases where the Preferred Billing Date is opted for, and if the payment of premium by such mode amounts
to advance payment of premium, then such amount will remain as an interest-free deposit with us and will

Note:
* Premium can be paid out of your own account or out of your Spouse, Parent or Childrens Account only. * Any cancellation, correction, alteration
etc. should be countersigned by the Account Holder. * Kindly ensure that the SI mandate form is signed by the account holder, even if the account
holder is different from the policy holder. * If the bank is unable to debit the account of the Policy Holder due to want of sufficient funds, the policy
holder will have to pay the premium by cheque/DD or cash at any of the branches of HDFC Standard Life Insurance Co. Ltd. before the grace
period ends, failing which the policy will lapse with/without a surrender value as applicable. * HDFC SL has the right to revoke the Standing
Instruction on event of the Instruction or change in the premium amount due to any alteration. * Direct debit facility (non ECS location) is offered by
ICICI Bank, Citibank, Corporation Bank, Union Bank of India, Bank of Baroda and Axis Bank only.
To be filled in by the account holders bank

Bank Stamp

Date

Authorised Signatory of the Bank

---------------------------------------------------------------------------------------------------------------------------------Introducing you to our wide range of value added services.

Track and Trace: You can track your proposal status online: 1. Log on to www.hdfcinsurance.com
2. Click on My Account
3. Click on Track Your Application
4. Enter the 16 digit application number (on the bar code)

Hassle Free Options: Your policy portfolio now available at your fingertips!
My Account- your very own customer portal

On the Move - avail of policy details on your mobile,

just call our contact center or
sms REG<space><policy number> to 5676727 or call
our contact center to register for this service
Premium payments made easy: Standing Instructions (SI) - a direct debit facility for all HDFC Bank account holders.
Electronic Clearing Service (ECS) - an auto debit facility available in more than
50 cities across India*
Online payments - available to all policyholders registered with billjunction.com or have
net banking facility. *
*Kindly check with your financial consultant to see if these services are available in your city.In case you wish to avail of any of these services
kindly fill in the service request form in the proposal document. If you opt for electronic clearing service kindly
Correspondence Address: Customer Service, HDFC Standard Life Insurance Co. Ltd, 5th Floor, B Wing, Eureka Towers,Mindspace complex, Link Road, Malad (West)

NRI Q - 6.6
FC Code No:

Non Resident Indian/ Person of Indian Origin Questionnaire.

We thank you for applying for an HDFC standard Life Insurance Policy. To enable us to assess your application, kindly send this NRI/ Person of
Indian Origin Questionnaire answered by the Life to be Assured and duly signed by the Life to be Assured and Proposed Policy Holder, if any.

Application No./Proposal No.

S100000134668

Name of Life to be Assured

Madhuresh

1. Address of foreign residence.

2. The name of your regular medical

physician while abroad, with full
contact information. -Telephone No,
Address, E-mail address, etc.
3. Permanent address in India.

Villa No 12 Tatvam Villas

Sohna Road
Haryana
122001

4. Nationality

INDIAN

Sector 48
Gurgaon
INDIA

5. a) Date of first leaving India.

5. b) Date when you intend to leave from India after
your current visit.
6. a) Duration of your stay abroad.
6. b) Date of return if known.
7. Purpose of your stay abroad.
8. Name and address of person to whom the policy
document is to be sent in India?

9. Please state your NRI Bank account number and

the name of the bank.
10. The source from which the premiums will be
paid?
11. a) Passport / PIO Card Number.
11. b) Date and place of issue.

An incomplete Questionnaire will not be considered valid.

I agree and understand the following:

1.The information given herein is true and complete in all respects and will form an integral part of the proposal made by me for an Insurance
policy from HDFC Standard Life Insurance Co. Ltd.
2.The policy as and when issued will be delivered to the address specified in Question No 8.

3.Similarly, the claim proceeds under such policies will be paid in India in Indian Currency.
4.The product has been sold to me in India and the proposal from is being signed by me in Indian territory.

Declaration of Life to be Assured:

I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by
me for an insurance policy from HDFC Standard Life Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate
the contract.

Signature/thumb impression
(Life to be Assured)

Signature/thumb impression
(Proposed Policy Holder if different

Date:
Place:

Date:
Place:

from Life to be Assured)

In the case of thumb impression\ signature in vernacular language:

In case of thumb impression of the Life to be Assured the same should be attested by a person of standing whose identity can be easily
established, but unconnected with the Company and this declaration should be made by him.

I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language and have truthfully recorded the
answers provided to me and that the Life to be Assured has signed /affixed thumb impression(s) above after fully understanding the contents
thereof.

Signature

Date:
Place:

Name and address of the declarant

In case of further clarification please contact your FC/ BDM/ CAM/ HDFCSL Branch office.

e-Insurance Account (eIA) Opening Form for Individual - To be used only if submitted along with the proposal form
Application No. / Proposal

S100000134668

A. Select the preferred insurance repository in which e-Insurance Account (eIA) needs to be opened:

B. AUTHORIZED REPRESENTATIVE DETAILS (mandatory)

Name*:

Date of Birth* (DD/MM/YYYY):

Gender*:

Relationship with eIA

Email ID*:

Mobile No*:

Address*:

Same as eIA

,,
City:

Pincode:

State:

Country:
I wish to notify Authorized Representative about his/her appointment

Authorised Representative Details for the eIA

An Authorized Representative is like a trustee to the e-Insurance Account (eIA) and has to be deputed by eIA holder. An Authorized
Representative is a person appointed by eIA holder who can access eIA in the event of the eIA holder's demise or in his incapacity to access
the eIA. The Authorized Representative can only access the e-Insurance Account and know the portfolio of insurance policies.

Declaration
The rules and regulations of Insurance Regulatory and Development Authority & Insurance Repository pertaining to an e-Insurance Account
which are in force now have been read by me and I have understood the same and I agree to abide by and to be bound by the rules as are in
force from time to time for such e-Insurance Account. I hereby declare that the particulars given herein are true, correct and complete to the
best of my knowledge and belief, the documents submitted along with this application are genuine and I am not making this application for the
purpose of contravention of any Act, Rules, Regulations or any statute or legislation or any Notifications, Directions issued by any
governmental or statutory authority from time to time. I authorise the Insurance Repository to send any policy and account related information
through email and SMS on the contact details given by me. In case of any physical policies being issued by the Insurance Company from
whom I obtain an epolicy, the address in the e-Insurance Account shall override the address provided for the physical policies. I understand
that all the communication relating to any physical/ e-policy will be sent to the address registered with the Insurance Repository. I agree to
inform the Repository of any changes in the details mentioned in this form and in case of delay the said repository shall not be liable in case it
acts on the said information which has not been updated. Further, in case I update the details with the Insurance Company, I authorise them to
submit the same to you for update in the e-Insurance Account and the said update will be applicable to all policies of any insurer that I hold/ will
hold in the said account. I authorise the Repository to pass on the information to any Insurance Company that I have approached for availing of
insurance cover.

I further agree that any false / misleading information given by me or suppression of any material fact will render my e-Insurance Account liable
for termination and further action.
I hereby authorise the Insurance Repository / Insurance Company to disclose, share, remit in any form, mode or manner, all / any of the
information provided by me to the respective Insurance Companies and / or to their authorised agents and representatives in which I may
transact / have transacted including all changes, updates to such information as and when provided by me.
I hereby agree to provide any additional information / documentation that may be required by the Authorised Parties, in connection with this
application. I hereby confirm that this is a unique e-Insurance Account opening application and I have not applied to the same Insurance
Repository or any other Insurance Repository for an e-Insurance Account in the past.
I would like to receive my insurance policy and all the information related to the proposed insurance policy through Insurance Repository.
I am aware the details furnished by me, including KYC documents, in/alogwith the proposal form will be used to open the eIA. I hereby give my
consent for the same.

Name of eIA Holder

HDFC STANDARD LIFE INSURANCE COMPANY LIMITED
11th Floor, Lodha Excelus, Apollo Mills Compound,
N M Joshi Marg, Mahalaxmi, Mumbai 400011
Regd. Office: Ramon House, H.T. Parekh Marg, 169,
Backbay Reclamation, Churchgate, Mumbai 400020

Signature
Call 1860-267-9999 (Local charges apply). DO NOT prefix any country
code e.g. +91 or 00. Call centre is open all 7 days from 9am to 9pm
SMS - SERVICE to 5676727 (Charges apply)
Email service@hdfclife.com
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