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Shriram Life Insurance Company Limited

(A joint venture with Sanlam Life Insurance Limited, South Africa)

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Regd. & Admn Office: 3-6-478, lll Floor, Anand Estate, Liberty Road, Himayat Nagar Hyderabad-500029 Ph: 23434466 72
(For Office use only) Proposal No : Customer ID : Dep. Receipt No : Rural Urban Agent/Sales Officer Name: Code: & Policy No : Inward Date : & Date : UIN: Photograph of Proposer if annual premium is more than Rs.10.000/-

GUIDELINES FOR FILLING UP THE PROPOSAL FORM: I. Insurance is a contract of utmost good faith which requires the proposal and the life to be assured to disclose all material facts in response to the questions in the proposal form. Before filling up the form, please read the product brochure so that you fully understand the benefits of the product, as well as the terms and conditions. II. Please fill in BLOCK LETTERS.
1.Details of Life to be assured : Name : Gender Male Female Nationality Indian NRI Educational Qualification :

Fathers Name : Age Proof Submitted (Specify): b. Occupation: Name of present employer : C. Annual Income (in Rs) : PAN Card No : 2. Name of the proposer if other than Life to be Assured 3. Address of the Proposer & Source : Aadhaar No : Relationship with Life to be assured: a. Date of Birth: Nature of Duties : Age :
(as on last birthday)

Funds Opted Name of the Fund Percentage (%)

D No:/St Area Landmark City / District State Contact No Email ID PIN Code :

4. Plan Details - Plan Name : Policy term Premium paying term Mode of premium payment Single / Quarterly / Half-Yearly / Yearly / Monthly ULIP Auto Transfer Option Yes No If Yes 6 Months 12 Months Sum proposed Installment premium Cash/DD/Cheque no: Particulars of Amount Deposited Date: Bank Name:

Name of Rider

Sum Proposed

Rider Term

5. Are you existing customer in Shriram? if yes, give details Loan / Ticket / Certificate No. 6. Nominee Details - Name of the Nominee : Age : Relationship with the Life to be Assured :

Appointee details (If the Nominee is a minor):- Name of the Appointee : Address for communication : Acceptance Signature of the Appointee: 7. Has your application for revival of your lapsed life insurance policy been rejected? If yes, give reasons 8. Please give details of your existing life insurance policies with any life insurance company? Name of Company Sum Insured Year in which policy was taken

8. Family History: Please give details of the family members of the Life to be assured. Family Member Father Mother Brothers Sisters If alive, age If dead, age at death

9. Personal Medical History of the life to be assured *. Answer the following in YES / NO- Tick
A. Height (in cms): C. Are you at present in good health? D. If answer to any of the below question is yes, please Give details of illness & enclose relevant reports 1.Are you physically handicapped or having any other deformity? 2.When were you in a hospital last? For how many days? For what illness? 3.Have you ever suffered from any of the following diseases? (i) Heart dysfunction (ii) Kidney dysfunction (iii) High blood pressure (iv) Diabetes (v) Cancer (vi) Liver dysfunction (vii) Blood abnormality (viii) Any other health ailment
Declaration by the Proposer / Life to be Assured: I hereby declare and agree that the statements and this declaration made under this proposal will be the basis of the contract of assurance between me and Shriram Life Insurance co. Ltd, and that if any Statement is untrue or inaccurate, or if any matter that might influence the terms of this Proposal is not disclosed, the contract shall be absolutely null and void and all premiums so for paid in respect of this contract shall stand forfeited to the company.I further agree that I will inform the company, if, between the date of this proposal and the date of acceptance of the proposal (issue of the first premium receipt),*There is any change in my general health, occupation, or financial position or,*Any other proposal or application to any other Insurance Company on my life is declined or accepted other than on standard terms so that the Company may reconsider the terms of acceptance. I also understand that if I fail to do so, the company may treat the contract as void and all premiums paid will be forfeited to the company.*I authorize and direct any doctor, hospital or employer to disclose to Shriram Life Insurance Co. Ltd. any information relating to health or employment now or at any time in the future, as and when required.*The contents of this proposal form have been fully explained to me & I have full understood the significance of the proposed contract. If an age proof extra, health extra or occupation extra has to be imposed, I hereby give my consent for imposing the same by reducing the sum proposed by me / by deducting from the allocated units.

the relevant Box

& (Please note that Strokes / Dots / Dashes are NOT accepted)

B. Weight (in kgs):

Yes No


Name Address Date Place

: : : :

Signature of Witness

Signature/thumb impression of the Proposer

Signature/thumb impression of the Life to be assured Note: (Signature of a Minor life assured is not required) Date: Place:

Declaration for signing in vernacular or for illiterate cases:(The company requires that this proposal is completed by the proposer himself. However, if this not possible as the proposer does not read, write or speak English, then this proposal form can be completed by another person who can read, speak and write English and who is not connected to the company either as an agent/employee or Insurance Intermediary)I have explained the contents of this proposal to the proposer and done my best to ensure that the contents have been fully understood by the proposer. I have accurately recorded the proposers responses to the information sought by the proposal form and I have read the responses back to the proposer and he/she has confirmed that they are correct.

Place Date

: : Name : Signature of the declarant in English

Section 41 of the insurance Act, 1938 : No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out, renew, or continue an insurance contract 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 rebates as may be allowed in accordance with the published prospectus or tables of the insurer. 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 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 a statement made in the proposal for insurance 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 policy, was in accurate or false, unless the insurer shows that such statement was on a material matter or suppressed fact which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose.

I have verified the information given in the proposal by discreet enquiries and find the information true to the best of my knowledge and belief. I am of the opinion that the Life proposed for insurance is insurable. I recommend the proposal for acceptance.

Signature of the Agent in English

Signature of an Authorised Official (equivalent to B.M)

Date: Place:
Note : If the policy is being taken by the agent on his/her own life, then the immediate superior/reporting officer equivalent to the designation of a Manager, should duly sign the proposal form recommending the Insurer to consider the proposal for a life insurance.