1800-102-4444 www.bharti-axalife.

com
Proposal No.:

121292

Bharti AXA Life eProtect Proposal Form

Proposal Form for Life Insurance
Insurance is a contract of utmost good faith and the Life to be Insured is required to disclose all material facts to the insurer. All answers to the questions stipulated in this Proposal form are the basis of and are an inseparable part of the policy of insurance. In case of doubt as to whether a fact is material or not, the fact should be disclosed. Please answer all questions. Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before filling this proposal form. Insurance is the subject matter of the solicitation.

1. Personal Information (SELF)

*All Fields Mandatory First Name i. Full Name* Middle Name Last Name

Janardhana rao

ii.

Maiden Name
(if married woman)*

First Name

Middle Name Last Name

chintada

iii. Father's Name *

First Name

Middle Name Last Name

ch Govinda rao

iv. v.

Place of Birth Gender *

(For married females, please state the maiden name)

srikakulam
Male Single Female Married Divorced Widowed

Date of Birth * 4

1987

vi. Marital status *

vii. Spouse Name*

First Name Last Name

Middle Name

viii. Nationality * ix. Residential Status * *All Fields Mandatory i. Educational Qualification * Others(Specify) Name of Organisation / Business * Duration of Current Employment*
(e.g. Trading in food grains/ Driving/Managing) *

Indian

NRI

Resident Indian

2. Employment Income Details Post Graduate

Others

ii. iii.

Bank Of India 1 years Salaried Marketing Manager No 8 months

iv. Exact Nature of duty

v.

Your Designation *

vi. Is Your Occupation associated with any specific Hazard (e.g.

Chemical factory,mines) *

vii. Annual income Rs * viii. Email Id *

420000 chjanardhanrao87@gmail.com

Bharti AXA Life eProtect Proposal Form ix. Age proof * Admission card LIC policy x. Pan number

2 of 4 Baptism or marriage certificate Passport Birth certificate

Proposal No.: 121292 Domicile certificate Driving licence

Employer service record Pan card

Government employment certificate School/college certificate

Identity card by defense department

In case of annualized premium in excess of Rs. 50,000, PAN is mandatory. If customer is not required to have PAN, Form 60 or 61 needs to be provided. Yes
s No

AJZPC1490N

xi. Are you an Existing Employee of Bharti & Axa Group xii. Photo Identity* xiii. Proof of Residence*

Passport *Telephone Bill

PAN Card *Ration Card

Voter's ID *Electricity Bill

Driving License *Bank Account Stmt

Others. *Others.

(*Proof submitted should not be dated more than six months prior to the date of proposal) xiv. Income proof
(Sum Assured>Rs.50 lac)

ITR

Employer Certificate

Salary Slip

Other

xv. Details of ongoing Conviction/criminal proceedings (if any): xvi. Are you a politically exposed person (PEP)?

No

No

PEPs are individuals who are or have been entrusted with prominent public functions, e.g., heads of States or of Governments, senior politicians, senior government/judicial/military officers, senior executives of state-owned corporations, important political party officials and also immediate family members of the aforesaid persons which would include spouse, children, parents, siblings, spouses parents or siblings and close associates)

3. Address Information (Please click here to ll address details)

Please provide address information for the purpose of communication. All mails, documents and calls would be sent/made to the address provided below

Current Residential Address * Address line 1 * Address line 2 Address line 3 Landmark * Pin code * City * District State * Phone * Mobile Permanent Address * Address line 1 * Address line 2 Address line 3 Landmark * Pin code * City * District State * Phone * Mobile Ofce Address * Address line 1 * Address line 2 Address line 3 Landmark * Pin code * City * District State * Phone * Mobile Same as Current Residential Address Yes

C/o Bank Of India, D.No : 27-21-39 Maa Naana Nilayam , Kaleswara rao road, Governorpeta
Landmark: City: State: Pin Code: ........ District: Phone:

520002

Congress office road vijayawada Andhra Pradesh

Krishna
Mobil

0866-2573165

0 8978549995

s No

S/o Ch. Govinda rao gopinagaram ( Vill) , Thotada (post) Dusi (Rs) Amadalavalsa ( Mandalam )
Landmark: City: State: Pin Code: ........ District: Phone:

532484

Near Rama layam srikakulam Andhra Pradesh

srikakulam
Mobil

0 8978549995

C/o Bank Of India, D.No : 27-21-39 Maa Naana Nilayam , Kaleswara rao road, Governorpeta
Landmark: City: State: Pin Code: :...... District: Phone:

532484

Congress office road vijayawada Andhra Pradesh

srikaulam
Mobile

0866-2573165

8978549995

All communications will be on the e-mail id mentioned above (if available). The mode of communication from and to the company would include electronic mode like sms, email etc. Physical copy Please tick 'Physical copy' if you want to receive communication in electronic form as well as physical Copy.

4. Nominee
(Not to be filled if Life to be Insured and Proposer are different) Ch Govinda Rao i. Name: Relationship to Life to be Insured: Date of Birth: % share:

29/03/1958 100

Father

ii. Name of Appointee (if Nominee is Minor): iii. Address:

Relationship of Appointee to Nominee:

Gopinagaram ( Village) Thotada (post) Dusi Rs Srikakulam

Bharti AXA Life eProtect Proposal Form

3 of 4

Proposal No.: 121292

5. Insurance History
LIFE INSURED i. Insurance History with Bharti AXA Life Insurance Company Do you have any existing Life Insurance cover that you bought from Bharti AXA/ or have made any similar application for Life cover with Bharti AXA Life? If yes, Please provide,

Details of existing insurance Policy/Proposal No.: Basic Sum Assured Policy Decision Status In Force In Force In Force ii. Insurance History with other Companies Do you have any existing Life Insurance cover that you bought from any other company? If Yes, please provide, . Details of existing insurance Policy/ Proposal No Date of Issue/ Proposal Lapsed Lapsed Lapsed

Company Name

Basic Sum Assured

Policy Decision

Status In Force In Force In Force Lapsed Lapsed Lapsed

647864697

LIC

27/01/2012

375000

Standard

6. Lifestyle and Personal Details (if "yes" to any question below please fill relevant questionnaire)
1. Do you plan to live or travel outside India for more than 100 days? If 'YES' please give details: 2 Do you take part or used to take part in any adventurous hobbies/ activities such as diving, gliding, mountaineering, rock climbing or any form of racing or any other hazardous activity/ hobby? 3 Have you in the past used or do you use any habit forming drugs or narcotics or received any drug abstinence treatment? If 'YES', please give details: 4. Do you consume alcohol? If YES specify per week consumption: Beer (Glasses) Hard Liquor (mls) Wine (mls) 5. Do you smoke or consume tobacco in any form, e.g., (paan, tobacco, gutka) or have done so in the past twelve months? If YES, specify per day consumption: Cigarette Sticks Cigar Sticks Bidi Sticks Gutka Pouch Paan 6. (a) Height 183 in (cm / feet and inches); Weight (in kgs) 86 (b) Has there been any variation in weight during the past twelve months? If YES, please mention gain/ loss (in kg) _____ Reasons: 7. Family Physicians Name: 8. Do you have any biological parents or siblings who have suffered from Diabetes, Stroke, Heart related conditions or any other genetic / hereditary disorders before age 55?

Life Insured Yes s No Yes s No Yes s No Yes s No Yes s No

Yes s No

Yes s No Yes s No

7. Health Records of Life to be Insured

If the answer to any of the questions below is "Yes", please give full details in the box below 1. Are you currently receiving any medical treatment or any you awaiting medical or surgical consultation, test or investigation? (You need not disclose matters relating to uncomplicated pregnancy, common colds, influenza, hay-fever or any minor ailment requiring a single consultation) 2. Have you ever had any medical or surgical treatment, including investigations, tests, scans or X-Ray for any of the following illnesses or medical conditions a) High blood pressure, angina, heart attack, stroke or any other disorder of heart or circulation? b) Any other respiratory or lung trouble e.g. Asthma, Bronchitis, persistent cough, Tuberculosis, pneumonia, coughing with blood etc? c) Diabetes or sugar in the urine? d) Disease or disorders of kidneys, bladder, prostrate or reproductive organs? e) Any disorder of the digestive system, gall bladder or liver? f) Cancer, enlarged gland, growth or tumor chemotherapy or radiotherapy of any kind? g) Anemia, bleeding or any other disorder of blood? h) Any nervous disorder or complaint of mental nature, Illness (Including Depression) lasting for more than 3 Months And/ Or Requiring More Than 10 Consecutive Days off Work? i) Disorder or disease of muscle, bones, joints, limbs, spine Arthritis or Gout? j) You or your spouse have tested positive indicating the presence of HIV/ AIDS, Hepatitis B or Hepatitis C? k) Any other illness, disorder,surgery, disability other than those listed above? Life Insured Yes s No

Yes s No Yes s No Yes Yes Yes Yes

s No s No s No s No

Yes s No Yes s No Yes s No Yes s No Yes s No

Bharti AXA Life eProtect Proposal Form 3. Do you have deformity or physical abnormality?

4 of 4

Proposal No.: 121292 Yes s No

4. For female lives: a) Are you pregnant? If YES, number of weeks b) Have you, or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy or confnement, e.g., Caesarian section or miscarriage, high blood pressure, gestational diabetes, etc? (If YES, state full details including dates)

Yes s No

Non-disclosure or incorrect disclosures to any of the above questions including health questions may lead to repudiation of the claim FURTHER DETAILS REGARDING ANY OF THE ABOVE QUESTIONS ANSWERED YES IN SECTION Question number(s) / Medical Condition: Date of diagnosis and Treatment given: Name of tablets or medications: Have you ever been hospitalised for this condition? Yes No Date of hospitalisation

Have you now fully recovered and stopped all medications? (if NO, give details)

8. Product Details
i. Product/Rider Name Sum Assured Policy Premium Policy Benet Premium Payment Premium Payment (Inclusive of Service Tax) Period Term Mode

Bharti AXA Life eProtect

6000000

35

35

Annual Semi annual

4921.00

* Semi-annual Premium = 0.52 of Annual Premium.

9. Premium Payment
Premium Payment by a person other than the life insured Yes No In accordance with IRDA (Manner of Receipt of Premium) Regulations, 2002 - Regulation 3(d), in case, the proposer opts for premium payment through credit/debit card, the payment should be made only through credit/debit card issued on the name of such proposer. The payment would be accepted in INR only. Proposer should use only his/her credit/ debit card or Internet banking account for payment

10. DECLARATION AND AUTHORISATION

I/We declare that I/we have received, read and fully understood the product brochure of Bharti AXA Life Insurance Company Limited (hereinafter referred to as the Company); declare that I/we fully understand the questions contained herein; declare that the statements and declarations made herein by me/us shall be the basis of the contract between me/us and the Company and that I/we enable the Company to make a decision about the acceptability of the proposal; declare that should any statement(s) be incomplete, false, wrong or inaccurate, or should there be any omission(s) on my/our part in disclosing the information, not notifed of the change in health,occupational or fnancial state, the Company shall have the right to cancel the Policy or repudiate the claim and forfeit any payments received; declare that I/we have made no statement to the agent, medical examiner or any other person associated with the Company, which in any way modifes the answers and statements in this proposal; declare that in the event of me/us being medically examined, the answers and statements made in this proposal form and the answers given by me/ us during the medical examination to the medical examiner acting on behalf of the company and as contained in the medical/ fnancial reports shall be deemed to be incorporated in the proposal form and become part of the life insurance policy, in case of acceptance of this proposal by the company; undertake to notify the Company forthwith, in writing, of any changes in my/our health, occupational and fnancial state and any proposal for insurance made with any other company between the date of this proposal and the date of the acceptance of risk by the Company; Confrm that no information other than for the purpose for underwriting and settlement of the claim shall be shared with any other insurance companies. understand and agree that no agent or medical examiner has the authority to waive or vary any stipulations or requirements set by the Company; understand and agree that to enable the Company to assess the risk under my/our proposal and at any time thereafter, I/we hereby authorize my/our past and present employer(s) or my/our business associates/medical practitioner/ hospital where I/we may have been admitted and treated or any other agency to disclose and make available to the Company such details and records as may be requested for by the Company; agree that the Company may provide any information available with the Company related to me/us or this proposal or the policy to any other insurer, reinsurers, insurance association, medical registrar or statutory authorities, without any reference to me/us; confrm that all premiums are and will be paid from bona fde and legally valid sources and will be declared to relevant tax authorities; understand and agree that the Company will be liable in pursuance of this proposal only after the risk commencement date; agree and confrm to the use of electronic medium, including email, as a mode for communication from and to the Company. also declare that there have been no criminal proceedings pending or commenced against me in the last fve years other than those stated herein before.also consent to receiving calls from the telecalling assist team of the Company. understand and agree that the company may call upon me to submit standard age proof, income proof and other KYC documents. I declare that I am submitting a proposal for life insurance to Bharti AXA Life Insurance Co. Ltd. through the Companys website. The information contained herein above is flled by me. I understand and agree that I will be bound by the information provided herein in the same manner as I would have been if a signed proposal form was submitted to the Company. SECTION 41 OF INSURANCE ACT 1938 (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out 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 pubished 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 satisfes the prescribed conditions establishing that he is bona fde 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. SECTION 45 OF 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 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 for insurance or in any report of a medical offcer, 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 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. 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.