Policy Number: 0322988336 Certificate of Existence [tecnica 1. Please answer all questions. 2. Please tick the box'_|where appropriate. 3. Please strike out parts which are not applicable and write 'N.A.. 4 Stroke of the pen, dots and dashes will not be accepted as replies. 5. This form is to be filled by the proposer himself/herself in BLOCK LETTERS in black or blue ink. 6. The proposer must sign any cancellation oralteration. 7. Insurance isa contract of utmost good faith, which requires the Insurer, proposer and lfe to be insured todisclose all material facts. Incase of any doubt asto whether afactis material or not, the fact should be disclosed. As. the statements in this proposal constitute warranties, complete and accurate information must be given. 8. The proposer mustsign on each page. 9. KYCdocuments of Policy Holder and witness will e required. nmol 2)PolicyNumber:_ ODRA GS SSB b Date: OR:10- AO) G b)LifeAssured'sName:__CHAND AS MERA PolicyHoldersName: _CHAND ASMERA d) Mobile: 3169S7 B62) _ e)Alternateno: 4165 26A6S6 _ A Emait' 9)PANNo: AAY PAGYUS7 F h) AadhaarNo.: uz 032720634 1 Dx Andhu ait, MBBS DMCH Ine Aste oy Mrs. © __(Name of Annuitant), Se FM. / Mrs. personally appeared before me on (date) along with his/her original identity documents (KYC) and signed in ‘mypresence. lam fullysatisfied about his/her identity. (pent conactno:F BAM RABE O weg Mo 2 Name of Atestng Authority: Dos. Angyhu Seu’ Ros so : pa ear pe Sespar ye: 6:10 209