IndiaFirst Life CSC “INSURANCE KHATA” Plan

Proposal No:______P50376827______, Name of the Distributor:____________, LG / Agent Code:______C1008642______, UIN No. 143N032V01

Instructions for filling the form:

1. Insurance is a contract of utmost good faith which requires the life to be insured to disclose all material facts.
2. The Life to be insured must read this document carefully and sign only after having fully understood its contents and their significance. In case any life to be insured cannot read English, he/she
must seek assistance to get the same translated.

1. Details of Life Assured.

Name:______SAYIKA PARVEEN MALIK______ Aadhar Number:____________

Date of Birth (only if Aadhar no. not available):______01-11-1988______

Gender (only if Aadhar no. not available): Male Female Transgender

Address (only if Aadhar no. not available):______HNO 49 WNO 1 CHOWKIAN______

______DARHAL MALKAN______
Policy Term:______5______ Premium Paying Term: Single Single Premium (with Taxes):______523______ Sum Assured:______2500______
Mobile Number:______7006472061______ Email ID:______CSCDARHAL@GMAIL.COM______

Nominee(s) Name Percentage Share Age of Nominee Relationship of Nominee Appointee Name (if applicable)

Mr. SHAHID MEHMOOD 100% 35 Husband

2. Health Declaration of Life to be Assured.

I hereby declare that I am in good health and I am not suffering and / or have not suffered from any illness / symptoms/ medical condition requiring medical treatment, medical investigation, surgery or
hospitalization in past 2 years.

YES NO

3. Bank Details.
Bank Account No:______0556040100002644______ Bank Account Type:______Saving Account______ Bank Name:______JAMMU AND KASHMIR BANK LIMITED______ IFSC
Code:______JAKA0DARHAL______

4. E-Insurance Account
Existing e - Insurance Account (e-IA) holder, please provide the e-IA details
e-IA Number____________ IR Name____________
Please check here to provide your consent to open a new e-IA Account

5. Declaration by the Life to be Assured

I/we hereby certify that I have been explained and have understood the contents of this proposal form and the responses to the proposal form have been provided by me. I further certify that I have
applied to purchase IndiaFirst Life CSC” INSURANCE KHATA” Plan from IndiaFirst Life Insurance Co. Ltd. and all information with respect to application no. __P50376827__ has been provided by
me truthfully, completely and correctly. I/we hereby declare that I have also gone through the sales material/IVR (English/ Hindi) and I have fully understood the product features and significance of
the proposed contract basis all the information provided. I / we further declare that I / we have not withheld any material fact or information which may affect the decision of IndiaFirst Life Insurance
Company Limited (Hereafter called the “Company”) in underwriting the risk, and the information provided by me / us in the proposal form, the supplementary documents and information provided to
the medical examiner in case of being medically examined will form the basis of the contract between me/us and the Company and in case of fraud, misrepresentation and suppression of material
facts the policy contract shall be treated in accordance with the Sec 45 of Insurance Act,1938 as amended from time to time. I / we hereby authorize and direct any doctor, hospital, or employer (past
and present) to disclose to the Company any information relating to my present state of health, past health history and nature of work performed by me / us. I / we undertake to undergo all medicals
as may be required by the Company to assess the risk and grant the insurance. I / we further agree that if after the date of submission of the proposal but before the issuance of policy (i) there is
an adverse change in my / us occupation, financial condition, health condition which will affect the decision of the Company in underwriting risk or (ii) if a proposal for assurance or an application for
revival of the policy on my / our life or the life to be assured made to any insurer is withdrawn or dropped, deferred, declined or accepted at an increased premium or subject to a lien or on terms other
than as proposed, I / we shall forthwith intimate the same to the Company in writing. Failure to do this on my / our part may render this assurance invalid and the policy will be dealt in accordance
with section 45 of the Insurance Act, 1938 as amended from time to time. I / we understand that the cover applied for under this application will commence after approval of my application and receipt
of the required premium by the Company. I / we, hereby declare that the premium have not been generated from proceeds of any criminal activities / offences listed in the Prevention of Money
Laundering Act 2002 or under any other applicable law.
I/we hereby declare that the Date of Birth, Health related questions and Financial status of Life to be Assured mentioned in proposal form is correct and true to my knowledge. In case the information disclosed
found to be incorrect or misrepresented claim will be treated in accordance with the Sec 45 of Insurance Act 1938 as amended from time to time

AML-KYC declaration:
I hereby give my unconditional consent to the Company to carry out due diligence in respect of information as provided by me in the proposal form.

____________________________ Date :______10-06-2019______

(Life to be assured signature / thump impression)
Place :______N/A______

OTP Verified
Signature authentication(Single factor authentication):
An OTP authentication number has been sent on your registered mobile number. By feeding in the said number in the system, you hereby unconditionally and absolutely acknowledge and accept the product features in its
entirety and the same would create a legally binding agreement between the Company and You.

Section 41 of Insurance Act 1938, as amended from time to time:

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 prospectus 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 bonafide insurance agent employed by the insurer. Any person making default in complying with the provisions of this
section shall be liable for a penalty which may extend to ten lakh rupees.

Section 45 of Insurance Act 1938, as amended from time to time:

The provisions of Sec. 45 of the Insurance act, 1938, as amended from time to time are applicable for the above contract. For more details please refer to our website www.indiafirstlife.com
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 Free Look Provision
You can cancel your plan if you disagree with any of the terms and conditions within the first 15 days for all channels except Distance Marketing where it is 30 days from receipt of the plan document,
while stating your reasons for your objection. In case of Non Linked Insurance Plans, you shall be entitled to a refund of the premium paid subject only to a deduction of a proportionate risk premium
for the period you were covered and the expenses incurred by us on medical examination if any and stamp duty charges. In respect of Unit Linked Insurance Plan, you will be entitled to a refund of
the Fund Value as on date of cancellation along with unallocated premium and charges levied by cancellation of units after deduction of pro rata mortality and the expenses incurred by us on medical
examination if any and stamp duty charges.

6. Intermediary details

Name of the Intermediary:____________ License Number:____________

(Applicable for all channels except Individual Agents)

Signature of the Agent / Specified Agents Stamp of the Intermediary

Name of the Agent / Specified Agents:____________ License Code:____________

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IRDA Registration No. 143. Registered and Corporate Office: IndiaFirst Life Insurance Company Limited. 301, 'B' Wing, The Qube, Infinity Park, Dindoshi - Film City Road, Malad (East), Mumbai - 400 097