(To be completed by Non Resident Indian or Foreign Nationals of Indian Origin)

1.

Full name of Life to be Assured :

2.

Proposal/Application number

3.

Nationality

4.
5.

Place of birth

Date of birth

6.

Details of passport held

Passport Number

Date of issue

Place of issue

7. Common ID no. Issued in country of residence e.g. (Social Security No, CPR, etc):

8. Full address in the country of your residence abroad :

9. Date from which you became the resident of the country mentioned above: ___ / ___ /____
10. Purpose of your stay abroad:

Occupation

Education

Personal

If education, provide following further details:

Name of University / Institution in which you are studying

Course details (including duration of the course and proposed date of completion of the Course)

11. Visa status:

Work VISA
Travel VISA
Residence VISA
Other ______
12. Duration of Your stay abroad: ______ Years.
13. Please indicate the manner by which you propose to remit the premiums
By cheques drawn on/ or debits your Non-Resident (External) or Foreign Currency Non
Resident Account) with Bank in India.
By the employers in respect of policies issued to their employees who have been deputed
abroad by them. Please obtain employees bank account number

14.

Details of Non Resident Account held in India:

A/c Number ____________________________________________________
Name of the Bank _______________________________________________
Address of the Bank Branch ______________________________________

15. Name, address and telephone number of your family physician in the country of your Current
residence

Declaration by the Life to be Insured / Proposer (if the life to be insured and proposer are two
different persons)
I, the undersigned, hereby confirm that the above statements and answers, given by me are full,
complete & true & I agree to treat this document as part of the original proposal form.
I hereby agree to pay all premiums in India and in Indian Rupees only and also agree that claims of
any nature arising under the policy will be settled by the Company in India and in Indian Rupees
only.
I also agree that any legal consequence(s) is subject to Indian jurisdiction only.
I confirm that this product has been solicited to me in person in India OR through e-mail /
telephone communication from India
I also undertake to comply with all the regulations/guidelines issued by Reserve Bank of India or
any other regulatory authority with reference to NRIs/PIOs and the related Insurance policies in
India from time to time.

Date: ________________

Signature of Life to be Assured

Place: _______________

Signature of Applicant/Proposer