Professional Documents
Culture Documents
I/We _______________________________________________request you to process the proposal with the above mentioned
application number submitted online/digitally on the company’s website www.bharti-axalife.com
Name of Insurance Plan _______________________________________________________________________________
The premium payable is ₹ ______________________ on a M Q HY Y frequency for a premium paying term of ___ years
& Sum Assured is ₹ _______________________________ From Agent Name & Code: _______________________________
Mobile No ______________________________ Email ID ___________________________________________________________
M - Monthly, Q - Quarterly, HY - Half Yearly, Y - Yearly
I/We understand that I/we may receive calls from Bharti AXA Life in relation to my application for insurance or the resulting policies. I/We give my consent to Bharti AXA Life to make such calls even
when I am/we are registered under NDNC category
DISCLAIMERS
I/We have received, read and fully understood the relevant documentation/information including the KEY feature document, Proposal Form
received from ___________________________@bharti-axalife.com and have understood and confirm to the product features and Illustration of
benefits and the information captured in the Proposal Form.
• I/We agree that the answers to the above questions are true and that this addendum forms a part of the proposal/contract between me/us and Bharti AXA Life. I 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. • I/We have submitted the proposal to buy this product on my/our accord after
having read and understood the terms and conditions of the said product on company’s website i.e. www.bharti-axalife.com. • I/We have verified the contents of the proposal form and understand and
agree that by submitting this proposal for Insurance through the company’s website, I/We will be bound by such statements/disclosures of material facts in the same manner and to the same extent
as if I/We had signed and submitted a written proposal for insurance after having read and understood the illustrations of benefits. • I/We fully understand the nature of the questions including health
related questions and the importance of disclosing all material information to the company while answering such questions in the proposal duly filled in online/digital by me or as per the information
provided by me. • I/We declare that answers given by me/us to all questions in the online proposal including the information given to the company as to the state of health & habits of the life/lives to
be insured are true and complete in every respect. • I/We undertake to notify the company forthwith, in writing of any changes in my/our health, occupational and financial state between the date of
this proposal and the date of the acceptance of the risk by the company. • I/We understand that any misstatement, suppression or non-disclosure of material information by me/us or where the
company is not notified of any change as mentioned above, the company shall have the right to cancel the policy or to repudiate the claim or to declare the policy void in accordance with Section 45 of
the Insurance Act and amount, if any, shall be refunded to the customer based on the policy terms and condition. I/We understand and confirm that the company shall have the sole and absolute
discretion to accept, decline or offer alternate terms on this proposal for life insurance. • I/We hereby declare and confirm that I/we am/are making the premium payment towards this proposal through
own bank account/credit card and I/we agree to submit a third party declaration in case the premium payment is not made from own account. • In case of premium payment through cash, I understand
and confirm that I will personally visit the branch office of the company for depositing the cash along with this Customer Declaration Form. • I/We further state and confirm that whatever is stated,
declared, confirmed or agreed above are done/effected on my/our own freewill and volition. • I consent agree and hereby state that I have no objection in authenticating myself with Aadhaar based
authentication system and UIDAI sharing of my Aadhaar details including name, father’s name, date of birth, address, mobile number, email id, gender and image for Aadhaar based validation/e-KYC
through biometric and/or One Time Pin (OTP) authentication for the purpose of availing Life Insurance Policy from Bharti AXA Life Insurance Co. Ltd. and servicing of said policy.
Ensure you know your policy details SIGNATURE OF PROPOSED POLICY HOLDER (if different)
SIGNATURE OF LIFE ASSURED
(This section needs to be filled only if ECS has been opted for)
I wish to pay my premium to Bharti AXA Life Insurance Co. Ltd. through a debit to my account on of the calendar.
Debit date can be opted from 1st to 28th. Please note debit date is not available for 29th, 30th and 31st.
DECLARATION: I, hereby declare that all information as provided in this proposal in connection with this proposal, pertaining to the medical, personal or financial standing of the proposer and having any material effect
on the acceptance of this proposal for insurance is true and complete to the best of my knowledge and belief. Should there be any adverse change in my opinion I shall inform the company of the same. I confirm that
I have verified the identity, current and permanent residential address of the proposer, the nature of his/her business and his/her financial status. Have verified the financial capacity of the proposer to determine that
the premium involved is within the proposer's financial capacity. I certify that I have explained the product brochure and the benefit illustrations to the Proposer and have made no statements which are inconsistent
with the same. I further declare that to the best of my knowledge the premium amounts are not sourced from proceeds of any criminal activities/offence listed in the Prevention of Money Laundering Act 2002. Should
there be any adverse change in my opinion of the integrity or reputation of the Proposer, I shall inform the Principal Compliance Officer of the company.
Financial/Advisor/Specified Person of Corporate Agent/Broker/Employee MOA’s/MOM’s/ Branch Sales Head/Senior Manager or above (Sales)
I confirm that I have met/spoken to the customer for the Life Insurance Proposal. I confirm that the customer is aware of all product features and
that the policy sold is in line with the customer’s requirements. The premium paying capacity of the said customer has been established. I have
also explained that there are no other benefits apart from the ones mentioned in policy terms & conditions.
I approve that the policy is Self-Policy and/or that is Splitting of Policy BSM Signature
Name ___________________________________________
Registered office: Unit 601 & 602, 6th Floor, Raheja Titanium, Off Western Express Highway, Goregaon(E), Mumbai 400 063.
Email: service@bharti-axalife.com, visit us at: www.bharti-axalife.com IRDAI Regd. No: 130, Comp No: Dec-2017-2998, CIN: U66010MH2005PLC157108