1 2 0 1 0 2 6

In case of a unit linked product, the investment risk in the investment portfolio under the Insurance policy will be borne by the Policyholder
Proposal Form for Life Insurance
Life / Financial Advisor / Specified Person of Corporate Agent / Employee of Broker Code (If applicable)____________________________________________________

Name___________________________________________________________________ Source Code (If applicable) ___________________________________________

Lead Generation Code “DSF”(If applicable)____________________________________ Type of Business: Rural Urban

MOA/MOM/Sales Manager/Corporate Agent/Broker Code (If applicable)______________________________________________________________________________

Name _____________________________________________________________________________________________________________________________________

Customer ID Policy No

Insurance is a contract of utmost good faith and the Life to be Insured/Proposer 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. In the event,
Life to be Insured/Proposer is unable to fill the form due to inability to read or understand the language, the help of another person may be used. (Refer to Section 10 - Declaration in case the
proposal form is filled by a person other than the proposer or signed in vernacular). Please answer all questions. If any of the questions are not applicable please write N.A and please tick a [box] ✓
where appropriate/applicable. Any correction/alteration in this form needs to be signed by the Life to be Insured/Proposer. Should you choose to pay premium by cash you are advised to do
deposit the same at the nearest branch office of the Company.
You are advised not to hand over cash to the sales person. The Company shall not be held responsible for any risk/loss arising out of the customer handing over any money to the sales person.
Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before filling this proposal form.
This form is to be filled by the Life to be Insured/Proposer in BLOCK LETTERS and a space should be left between each word.

1. About Myself

Section A
PARAMETERS LIFE INSURED PROPOSER
1. First Name First Name First Name
S A G A R
Life to be Insured

✔ Mr.  Mrs.  Ms. Middle Name Middle Name
M A N O H A R
Proposer
Last Name Last Name
 Mr.  Mrs.  Ms.  M/s
P A W A R

2. Place and Date of Birth 2 9 0 5 1 9 9 2

3. Father/Spouse Name M A N O H A R V I T H O B A

4. Correspondence Address C - 1 0 4 , S A I K U N J S
(if different for Life to be Insured
and Proposer)
J A D H A V W A D I
Landmark Landmark
C H I K H A L I
Village Village

Taluka Taluka

City City
P U N E
Pincode Pincode
4 1 1 0 6 2
State State

5. Permanent Address A / P - G H A R N I K I

T A L - A T P A D I
City City
S A N G L I
Pincode Pincode
4 1 5 3 0 8
State State
 6. Gender & Nationality ✔ Male  Female  ✔ Indian  NRI  Others _____________  Male  Female  Indian  NRI  Others _____________

7. Marital Status 
✔ Single  Married  Divorced  Widowed  Single  Married  Divorced  Widowed
(for married females, please
mention maiden name)
Office Mobile Office Mobile
8. Contact Number
(with STD code) / Email ID 9 8 9 0 0 0 7 3 9 6
Resi Mobile Resi Mobile

Email SAGAR.M.PAWAR.2929@GMAIL.COM Email

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.
Please tick 'Email' if you want to receive mandatory communication in electronic form. Email 
9. Age Proof  Birth Certificate  Passport  PAN Card  Driving License  Birth Certificate  Passport  PAN Card  Driving License
(Self Attested)
 School / College Certificate  Other (Specify) ________________  School / College Certificate  Other (Specify) ________________

10. Education  Professional  Post Graduate ✔ Graduate  Diploma  Professional  Post Graduate  Graduate  Diploma
 12th Pass  10th Pass  Below 10th  Illiterate  12th Pass  10th Pass  Below 10th  Illiterate
11. Employment Details  Salaried  Professional  Business  Student  Retired 
✔ Salaried  Professional  Business  Student  Retired
 Housewife  Self-Emp  Agriculture  Others_____________  Housewife  Self-Emp  Agriculture  Others_____________
Section B
1. Name and address of Em- M A H A L A X M I F A B R I C
ployer / Business

2. Designation and period of ENGINEER

working
Years ___________
01 Months ___________
00 Years ___________ Months ___________

3. Job Description SALARIED

4. Annual Income (Total) Rs. 3,20,050 Rs.

5. Source of Income

6. PAN(Permanent Account B J P P P 4 2 4 6 N
Number) ##

7. Relationship of Proposer to
the Insured  Father  Mother  Spouse  Employer 
✔ Other (specify) _________________________________________________________

8. Photo Identity  Passport  PAN Card  Voter’s ID  Driving License  Passport  PAN Card  Voter’s ID  Driving License
 Others_______________________________________________  Others_______________________________________________

9. Proof of Residence  Telephone Bill*  Ration Card  Electricity Bill*  Telephone Bill*  Ration Card  Electricity Bill*
 Bank Account st#  Others______________________________  Bank Account st#  Others______________________________
“(*Proof submitted should not be more than three months prior to the date of proposal) (Current and Permanent Residence proof of Proposer is
mandatory)(# Bank Account Statement submitted should not be more than one month prior to the date of proposal)”
10. Are you a politically exposed
person (PEP)?  Yes  ✔ No  Yes  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 of-
ficers, senior executives of state-owned corporations, important political party of ficials and also immediate family members of the aforesaid persons which would include spouse, children,
parents, siblings, spouse’s parents or siblings and close associates)
11. Income proof submitted (if  ITR  Employer Certificate  Salary Slip  ITR  Employer Certificate  Salary Slip
applicable):
 Other (specify) ________________________________________  Other (specify) ________________________________________

12. Purpose of Insurance  Savings  Protection  Investment  Savings  Protection  Investment

 Other (specify) ________________________________________  Other (specify) ________________________________________

13. Details of ongoing Convic- NO

tion / criminal proceedings (if
any):

14. Today,________________, Are you a tax resident of any other country(ies), Other than India ?
if Yes, Please provide Name or such country(ies) and TIN (Tax Indentification Number) with respect to each reportable jurisdiction:

i) Name of Country
ii) Name of Country
iii) Name of Country
iv) Name of Country
v) Name of Country
* If you are unsure of your tax residency, please check with your personal tax consultant
** If your tax residency changes after the date here-above mentioned, please kindly let us know within 30 days of such change.
***You are required to state the residency for tax purposes of the person or persons identified as the policyholder.

2. Product Details
Product/Rider Name Sum Assured Premium Payment Term Policy Benefit Period
BHARTI AXA LIFE PREMIER PROTECT PLAN
Premium Payment Mode Renewal Premium Payment Method
75,00,000 047 47
 Single  Quarterly  ECS**  Credit Card**
 Annual  Monthly
✔
 Cheque/DD/Cash#
 Semi-annual  Other (specify)_________________
✔
 #Not available for Monthly & Quarterly Mode; **Please submit the specified form

Applicable for Bharti AXA Life Hospi Cash Rider, attachable to non linked products only (Please tick any one based on your choice of DHCB).
DHCB Options
 Rs. 1000  Rs. 2000  Rs. 3000

ii. Premium Details : Base Plan (Rs.)_______________________Rider

618 Premium (Rs.)______________________Non Standard age Proof charges, if applicable (Rs.)______________________ Total amount
paid (Rs.)______________________Mode
729 of payment:  Cash  Cheque  DD  Other (specify)_____________________________________________________________

Applicable only for Bharti AXA Life Shining Stars Plan

Maturity Payout Option : Flexi Payout Option Annual Payout Option

Flexi Payout Option - 100% of Sum Assured is paid at the time of Maturity. Flexibility to receive Maturity Benefit as a lumpsum amount at the end of any year during the Maturity Payout
periodAnnual Payout Option - 22% of the Sum Assured is paid as five equal annual payouts at the end of every year during the Maturity Payout Period starting from the date of maturity.
Maturity Payout period is the period of 4 years from the date of maturity. The choice of the options can be taken either at policy inception or at least 90 days before the date of maturity.

iii. Cheque / DD details : Date ___________________ Cheque/DD No. ___________________Issuing Bank Name:______________________________ Payable at Branch _________________
A/c No.___________________________________________________ (Cheque / DD should be made payable to “Bharti AXA Life Insurance Company Limited”)
iv. Premium Payment through cheque by a person other than the proposer  Yes  No Relation with the proposer___________________________________________________________
v. Details required for NEFT Transfer: Bank Account Holder’s Name: ______________________________________________________ Bank Account Number: __________________________
Bank Name: ________________________________________________________________________________ Bank Branch Name: _______________________________________________
Type of account: _________________________________ IFSC Code: ________________________________ MICR Code:: __________________________________
I / We authorize/ confirm/ declare Bharti AXA Life Insurance (‘the Company’) • to make all Policy related payments (excluding death Claims) through electronic transfer to the Bank Account as specified above; Will inform the
Company about any change in the Bank Account details (as mentioned above) and understand and agree that the change will be effective only on the Company executing the change in their records as per the request received from me;
Would not hold the Company responsible in case of non-credit of payments to my bank account or if the transaction is delayed or not effected for reasons of incomplete / incorrect information provided by me. All Policy related
payments (excluding death Claims) shall be paid by INR only. “Note- Please attach an original personalized cancelled cheque / latest 3 month Bank statement for the above account number”

vi. Fund Allocation* (Choosing Growth Opportunities Plus Grow Money Plus Build India
a fund is mandatory with min. _____% _____% _____%
TOTAL = 100%
5%) (applicable only for Unit Save ‘n’ Grow Money *Applicable for Unit Steady Money Safe Money
Linked products only
Linked Policies) _____% _____% _____%

3. Nominee
(Not to be filled if Life to be Insured and Proposer are different)
Name Date of Birth Signature of Nominee Relationship to Life to be Insured % Share
i. MANOHAR VITHOBA PAWAR 01/06/1960 FATHER 100
ii.

iii.

iv.

v.
Name of Appointee (if Nominee is Minor):_________________________________________ Relationship of Appointee to Nominee ___________________________________________
Address_____________________________________________________________________ Signature of Appointee ________________________________________________________

4. Insurance History
LIFE INSURED PROPOSER (to be filled if proposer opts for Premium Waiver Rider)
i. Details of Policy / Pro- Company Date of Issue/ Sum Assured In Force / i. Details of Policy / Pro- Company Date of Issue/ Sum Assured In Force /
existing / posal No. Name Proposal Lapsed existing / posal No. Name Proposal Lapsed
Proposed Proposed
Insurance Insurance

ii. Details of Family Income and family Insurance

a. For unemployed: if single, provide family insurance. If married, then Spouse insurance b. To be filled only if Life to be Insured is Minor
Relationship to Life to be Insured Relationship to Life to be Insured
 Spouse  Father  Mother  Father  Mother  Brother(s)  Sister(s)
Total Sum Assured Total Sum Assured
Income Are all the siblings Insured
 Yes  No
If No, give detail:

5. Lifestyle And Personal Details (if “yes” to any question below please fill relevant questionnaire)

Life Insured Proposer

1. Do you plan to live or travel outside India for more than 30 days?
 Yes  No ✔
 Yes  No
If ‘yes’ please give details: _____________________________________________________________________________________________
2. Have you in the past used or do you use any habit forming drugs or narcotics or received any drug abstinence treatment?
 Yes  No ✔
 Yes  No
If ‘yes’ please give details: _____________________________________________________________________________________________

3. Do you consume alcohol? If YES specify per week consumption: Beer (Glasses)________Hard Liquor(mls)________Wine(mls)________  Yes  No ✔
 Yes  No
4. Do you smoke or consume tobacco in any form e.g (paan, tobacco, gutka) or have done so in the past twelve months?
 Yes  No ✔
 Yes  No
For Life Insured: If “YES”, Specify per day consumption: Cigarettes sticks________Cigar sticks________Bidi sticks________
Gutkha Pouch________Paan________
For Proposer: If “YES”, Specify per day consumption: Cigarettes sticks________Cigar sticks________Bidi sticks________
Gutkha Pouch________Paan________
5. (a) For Life Insured: Height________in
05/09 (cm/ feet and inches) Weight (in Kgs)________;
088 (b) Has there been any variation in weight
FALSE
 Yes  No
✔
 Yes  No
during the past twelve months? If Yes, please mention gain/ loss (in kg)________Reasons ________________________________________
(b) For Proposer: ________in (cm/ feet and inches) Weight (in Kgs)________; (b) Has there been any variation in weight
during the past twelve months? If Yes, please mention gain/ loss (in kg)________Reasons ________________________________________

6. Family Physician’s Name and Contact No. _______________________________________________________________________________

 6. Family History
Life Insured Proposer (to be filled if proposer opts for Premium Waiver Rider)
Family Member Living Deceased Living Deceased
Age Heath Status Age at Death Cause of Death Age Heath Status Age at Death Cause of Death
(for cancer include site) (for cancer include site)

Father 60 FIT
Mother 52 FIT

Spouse
Brother(s)
Sister(s)
Son(s)
Daughter(s)

7. Health Records of Life to be Insured (Proposer answers to be filled if proposer opts for Premium Waiver Rider)
If the answer to any of the questions below is “YES”, please give full details in the box below or complete relevant questionnaire wherever applicable.
Life Insured Proposer
1. Has any application for life, critical illness or health insurance on your life ever been declined, deferred or accepted with higher than
standard premiums or an exclusion applied on health grounds?  Yes  No
✔
 Yes  No
2. Have you ever been incapable to work for more than 7 days or presently incapable to work?  Yes  No
✔
 Yes  No
3. Do you expose yourself to any danger in the pursuance of your occupation (e.g. Chemical factory ,mines) or intend to engage in any
dangerous pursuits such as skydiving, parachuting, hang gliding, motor sports, diving, climbing, caving, or any other dangerous sports or are  Yes  No
✔
 Yes  No
involved in aviation as a pilot, co-pilot, pilot instructor or student pilot?
4. Have you ever had or received medical advice or treatment for any of the following?
a. disorders of blood pressure, chest pain, any heart disease, stroke, epilepsy, cancer (including skin cancers) or any tumor, lump,  Yes  No
✔
 Yes  No
cyst, polyps or growth of any kind
b. asthma or any respiratory disease, kidney or urinary tract disease, mental or any nervous disease, any liver disease, any blood
disorders (including anaemia), any digestive and bowel disorder, raised blood sugars, any metabolic or endocrine disorder (including  Yes  No
✔
 Yes  No
thyroid disor-ders), disorders of ears or eyes, problem of stones in any organ in the body

c. any disorder of the bones, spine or muscle, auto immune diseases  Yes  No
✔
 Yes  No
d. HIV infection, AIDS or AIDS related complex, tuberculosis, lyme, alcohol or drug dependency  Yes  No
✔
 Yes  No
e. congenital/birth defects  Yes  No
✔
 Yes  No
5. Are you currently receiving any medical treatment or do you intend seeking or have been advised to seek medical treatment for any
health problems or are you waiting the results of any tests/investigations?  Yes  No
✔
 Yes  No
6. Apart from condition listed, have you ever seen a Doctor or other health professional, or been prescribed medication for any other
condi-tion which has lasted for more than (apart from usual flue and colds) 5 days?  Yes  No
✔
 Yes  No
7. Has your biological mother, father, or any sister or brother been diagnosed prior to age 60 with any of the following? Cancer, Heart
attack, Diabetes , Stroke, Huntington’s disease or any other inherited conditions?  Yes  No
✔
 Yes  No
8. For female lives: a) Are you pregnant? If “YES”, number of weeks___________  Yes  No  Yes  No
b) Have you, or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy or conf
ine-ment e.g. Caesarian section or miscarriage, high blood pressure, gestational diabetes, etc?  Yes  No  Yes  No
(If “YES” state full details including dates)_________________________________________________________________________________
Incorrect/Non-disclosure to any of the above health questions will lead to the Policy contract being "voidable" at the option of Insurer and hence any application for claim under this
policy will be considered as INVALID & NON-ADMISSIBLE
FURTHER DETAILS REGARDING ANY OF THE ABOVE QUESTIONS ANSWERED “YES” IN SECTION 7
Life Insured Proposer
Question number(s) / Medical Condition
Date of diagnosis and treatment given
Name of tablets or medications
Have you ever been hospitalized for this condition?
 Yes  No  Yes  No
Date of Hospitalization Date of Hospitalization

Have you now fully recovered and stopped all medications? (if No,
give details):
Details of declined / postponed proposals

Name of the Company

Reason

When

8. ANNEXURE FOR INSURANCE REPOSITORY

1.Do you have an eIA account number? If yes, please provide __ (Mandatory if Answer is “Yes”)_____________________________________  Yes  No ✔

2. If no, would you like to apply? (Mandatory if Answer to Q1 is “No”, if yes to Qs 2, please submit eIA request form)
 Yes  No
✔

3. Would you like to have an e policy? (Mandatory if answer to either of the Q1 or Q2 is “Yes”)
 Yes  No
✔

4. Specify the Insurance Repository Name for eIA creation. List of Insurance Repository:
 NSDL Data Management Limited  Central Depository Services Limited  SHCIL Projects Limited  Karvy Insurance repository Limited  CAMS Repository Services
✔
 9. DECLARATION AND AUTHORIZATION
1. I/We declare and confirm that all the replies to the questions in the proposal, the details furnished in the enclosed questionnaires and the reports of any medical examination or are
provided to the best of my knowledge. I/ We declare that no material information required by the Company to assess the risk on my life is withheld with me.
2. In order to enable the Company to assess the risk under this proposal and any time thereafter, I/We hereby authorize the past and present employer(s)/ business associates of mine, my
medical practitioner/ hospital/ medical source/ any life and non-life Insurance Company/ organization to release to the Company the records of employment/ business or other details of
mine as may be considered relevant for acceptance or otherwise of the proposal.
3. I/ We declare that the deposit towards the first premium and the renewal premium to be paid under the Policy are from legal sources of Income.
4. I/We undertake to notify the Company forthwith, in writing, of any changes in my/our health, occupational and financial 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.
5. I/ We hereby understand and agree that Fraud or Misrepresentation would be dealt with in accordance with the provisions of Section 45 of Insurance Act, 1938 as amended from time to
time.
6. I/We agree and confirm to the use of electronic medium, including email, as a mode for communication from and to the Company.
7. I/We hereby understand and agree that the replies to the questions in the proposal, the details furnished in the enclosed questionnaires, the reports of any medical examination, or
laboratory tests, my proof of age and this declaration will be the basis of the contract of assurance between me and Bharti AXA Life Insurance Company Ltd ( the “Company'') and that if
any statement made in the proposal for insurance or to any medical examiner, or referee, or in any other document leading to the issue of the policy is inaccurate or false, is on a material
matter or facts which is material to disclose ,or if any information provided or disclosure made by me/us at the time of proposal are in variance with my/own financial position or health
condition, physical or mental, as at the time of proposal or if any of the documents submitted by me is found to be fake or forged then action will be taken immediately to voidable the
contract. In case of fraud, misrepresentation and suppression of material facts the policy contract shall be treated in accordance with the Section 45 of Insurance Act, 1938 as amended
from time to time.
8. I/We agree and declare that the Company may without any reference to me (or to my beneficiary, as the case may be) disclose any information contained in the proposal, the annexure,
in the reports of any medical examination / laboratory tests or in the documents submitted by me / or procured by the Company to any other insurer or to any reinsurer, to any claims
investigator or any service provider engaged by the Company for issuance, servicing and claim processing of the policies. Likewise the Company may make available copies of the
proposal form, annexures, reports of any medical examination laboratory tests or any documents submitted by me(or, as the case may be, by my beneficiary) or procured by the Company
to any insurer to any claims investigator or any service provider engaged by the Company for servicing the policies. So also the Company may without any reference tome (or, as the case
may be, to my beneficiary) furnish to any court / tribunal or other authority any such information or proposal, annexure, reports or documents as may be required of the Company or as
may be considered necessary by the Company.
9. I will abide by Company’s directions on medicals through any medium. The Company or Company’s representative/s may contact me/ us at the address provided in the proposal form

I declare that should any statement(s) including health declaration be incomplete, false, wrong or inaccurate, or should there be any omission(s) or withholding of information on my/our part,
the company shall have the right to cancel the policy. The Policy will be cancelled immediately, subject to the fraud or misrepresentation being established by the company in accordance
with Section 45 o f the Insurance Act, 1938

Life to be Insured Proposer (If different from Life to be Insured)

Signature*

Date
Place
*The proposer / Life Insured can upload a scanned copy of
their signature in the above box
Name/Address of Witness

SECTION 41 OF INSURANCE ACT 1938 as amended from time to time

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 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.

2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakh rupees.

Fraud, Misrepresentation and forfeiture would be dealt with in accordance with provisions of Section 45 of the Insurance Act 1938 as amended from time to time.
(1) No Policy of Life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy, i.e., from the date of issuance of the policy or the
date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2) A Policy of Life Insurance can be called in question within 3 years from the date of commencement of the risk or date of revival or date of rider to the policy, whichever is later, either or
account of fraud or on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document
on the basis of which the policy was issued or revived or rider issued.
(3) However, no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to the best
of his knowledge and belief or that there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of a material fact are within the knowledge of the
insurer
(4) In case the policy is repudiated on the ground of misstatement or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudia-
tion shall be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the date of such repudiation.
(5) 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.
(For complete details of Section 45, please refer to Annexure I of Product Brochure)

Bharti AXA Life Insurance Company Limited

Registered address- Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor, Malad link road, Malad (west), Mumbai 400064. Maharashtra
Email: service@bharti-axalife.com, visit us at: www.bharti-axalife.com, Regn. No: 130. Advt No.: Comp-March-2015-2635
BHARTI AXA LIFE PREMIER PROTECT PLAN PROPOSAL FORM Proposal No.: 1201026

Addendum 1

Proposer Personal Details

Email Id SAGAR.M.PAWAR.2929@GMAIL.COM

Employment Details Others --

Relationship of proposer to the Insured Others --

Photo Identity Others --

Proof of Residence --

Age Proof --

Income Proof --

Purpose of Insurance --

Nominee Address

Policy Proposal Declined Reason

All Siblings Insured No Reason --

Medical City --

Grand Parent NOC - I/ We the grandfather / grandmother of the life

assured hereby declare that the parents ( mother / father ) of life
--
assured have no objection in taking the policy in the name of life
assured .

C-104, SAIKUNJ SOCIETY, JADHAVWADI, CHIKHALI, PUNE,

Correspondence Address
411062, 9890007396

A/P-GHARNIKI, TAL-ATPADI, DIST-SANGLI, VITA ROAD, SANGLI,

Permanent Address
415308, 9890007396

Organization Or Business Name MAHALAXMI FABRICATORS WORK

A/P-PAHUNEWADI, TAL-BARAMATI, PHALTAN ROAD, PUNE,

Office Address
413102

Premium Return Type --

Disclaimer:
The Proposer hereby declares and confirms that the personal Information and medical information of the Life to be insured submitted by me is
true and to the best of my knowledge & belief.
BHARTI AXA LIFE PREMIER PROTECT PLAN PROPOSAL FORM Proposal No.: 1201026

Addendum 2

Proposer Insurace History Details

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. * Sum Assured * Policy Decision * Status

- - - -

Details of Existing Insurance History with Other Companies

Policy/Proposal Date of
Company Name * Sum Assured * Policy Decision * Status
No. Issue/Proposal
- - - - - -

Nominee

Nominee Name DOB Relation of LA Percentage of Share

MANOHAR VITHOBA PAWAR 01/06/1960 FATHER 100

Details of Family Annual Income and Family Insurance

Relationship to Life to be Insured Total Sum Assured Annual Income

-- -- --
BHARTI AXA LIFE PREMIER PROTECT PLAN PROPOSAL FORM Proposal No.: 1201026

Addendum 3

Proposer Family History Details

Age/ Health Status/

Family Member Status
Age at Death Cause of Death

Father LIVING 60 FIT

Mother LIVING 52 FIT

Have any of your parents, brothers or sisters had high blood pressure, cancer, diabetes prior to age 60 or any hereditary or chronic disorder ?

NO

Reason:
BHARTI AXA LIFE PREMIER PROTECT PLAN PROPOSAL FORM Proposal No.: 1201026

Addendum 4
Proposer Lifestyle & Health Details

1. Do you plan to live or travel outside India for more than 30 days?
NO
If 'yes' please give details:

2. Have you in the past five years flown as a pilot, co-pilot , pilot instructor, student pilot or do you have any intent to fly?
NO
If 'yes' please give details:

4. Have you in the past used or do you use any habit forming drugs or narcotics or received any drug abstinence
treatment? NO
If 'yes' please give details:

5. Do you consume alcohol?

If yes specify per week consumption: Beer (Glasses) NO

Hard Liquor (mls)
Wine (mls)

8. Family Physicians Name:

NO
If yes please give details:--

1. Has any application for life, critical illness or health insurance on your life ever been declined, deferred or accepted with
higher than standard premiums or an exclusion applied on health grounds?
NO
Company Name: Date of Decline:
Reason for Decline:

2. Have you ever been incapable to work for more than 7 days or presently incapable to work?
NO
Incapable Reason:

3. Do you expose yourself to any danger in the pursuance of your occupation (e.g. Chemical factory ,mines) or intend to
engage in any dangerous pursuits such as skydiving, parachuting, hang gliding, motor sports, diving, climbing, caving, or
any other dangerous sports or are involved in aviation as a pilot, co-pilot, pilot instructor or student pilot? NO

Reason:

4. Have you ever had or received medical advice or treatment for any of the following:
a) disorders of blood pressure, chest pain, any heart disease, stroke, epilepsy, cancer (including skin cancers) or any
tumor, lump, cyst, polyps or growth of any kind?
Medical condition: Date of diagnosis: NO

Treatment given, name of tablets or medications:

Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

b) asthma or any respiratory disease, kidney or urinary tract disease, mental or any nervous disease, any liver disease, any
blood disorders (including anaemia), any digestive and bowel disorder, raised blood sugars, any metabolic or endocrine
disorder (including thyroid disorders), disorders of ears or eyes, problem of stones in any organ in the body?
Medical condition: Date of diagnosis: NO
Treatment given, name of tablets or medications:
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

c) any disorder of the bones, spine or muscle, auto immune diseases?

Medical condition: Date of diagnosis:
Treatment given, name of tablets or medications: NO
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):
d) HIV infection, AIDS or AIDS related complex, tuberculosis, lyme, alcohol or drug dependency?
Medical condition: Date of diagnosis:
Treatment given, name of tablets or medications: NO
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

e) congenital/birth defects?
Medical condition: Date of diagnosis:
Treatment given, name of tablets or medications: NO
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

5. Are you currently receiving any medical treatment or do you intend seeking or have been advised to seek medical
treatment for any health problems or are you waiting the results of any tests/investigations?
Medical condition: Date of diagnosis:
NO
Treatment given, name of tablets or medications:
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

6. Apart from condition listed, have you ever seen a Doctor or other health professional, or been prescribed medication for
any other condition which has lasted for more than (apart from usual flue and colds) 5 days?
Medical condition: Date of diagnosis:
NO
Treatment given, name of tablets or medications:
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

7. Has your biological mother, father, or any sister or brother been diagnosed prior to age 60 with any of the following?
Cancer, Heart attack, Diabetes , Stroke, Huntingtons disease or any other inherited conditions?
Medical condition: Date of diagnosis:
NO
Treatment given, name of tablets or medications:
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):

8. For female lives:

NO
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 confinement e.g. Caesarian section or miscarriage, high blood pressure, gestational diabetes, etc?
Medical condition: Date of diagnosis:
Treatment given, name of tablets or medications:
Have you ever been hospitalized for this condition? (if "Yes") Date of hospitalization:
Have you now fully recovered and stopped all medications? (if No, give details):
BHARTI AXA LIFE PREMIER PROTECT PLAN PROPOSAL FORM Proposal No.: 1201026

Declaration

1. I/We declare and confirm that all the replies to the questions in the proposal, the details furnished in the enclosed questionnaires and the
reports of any medical examination or are provided to the best of my knowledge. I/ We declare that no material information required by the
Company to assess the risky on my life is withheld with me.
2. In order to enable the Company to assess the risk under this proposal and any time thereafter, I/We hereby authorize the past and present
employer(s)/ business associates of mine, my medical practitioner/ hospital/ medical source/ any life and non-life Insurance Company/
organization or Life Insurance Association to release to the Company the records of employment/ business or other details of mine as may be
considered relevant for acceptance or otherwise of the proposal.
3. I/ We declare that the deposit towards the first premium and the renewal premium to be paid under the Policy are from legally assessed
source of Income. In case the premium is paid from any other account other than my /our own, I/we shall ensure that such payment is permitted
under Section 80C/80CCC of the Income Tax Act, 1961. I/We declare that in case I/we are found guilty of any offence relating to Anti Money
Laundering law, the Company will be in within the rights to cancel the policy issued pursuant to this proposal & forfeit all the premium.
4. I/We undertake to notify the Company forthwith, in writing, of any changes in my/our health, occupational and financial 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.
5. I/ We hereby understand and agree that Fraud or Misrepresentation would be dealt with in accordance with the provisions of Section 45 of
Insurance Act, 1938 as amended from time to time.
6. I/We agree and confirm to the use of electronic medium, including email, as a mode for communication from and to the Company.
7. I/We hereby understand and agree that the replies to the questions in the proposal, the details furnished in the enclosed questionnaires, the
reports of any medical examination, or laboratory tests, my proof of age and this declaration will be the basis of the contract of assurance
between me and Bharti AXA Life Insurance Company Ltd ( the “Company'') and that if any statement made in the proposal for insurance or to
any medical examiner, or referee, or friend of mine, or in any other document leading to the issue of the policy is inaccurate or false, is on a
material matter or facts which is material to disclose ,or if any information provided or disclosure made by me/us at the time of proposal are in
variance with my/own financial position or health condition, physical or mental, as at the time of proposal or if any of the documents submitted by
me is found to be fake or forged then action will be taken immediately as per provisions of Section 45 of Insurance Act 1938 as amended from
time to time to either cancel the Policy and refund the premium or take action against fraud as per provisions of section 45 of Insurance Act,
1938 as amended from time to time.
8. I/We agree and declare that the Company may without any reference to me (or to my beneficiary, as the case may be) disclose any
information contained in the proposal, the annexure, in the reports of any medical examination / laboratory tests or in the documents submitted
by me / or procured by the Company to any other insurer or to any reinsurer, to any claims investigator or any service provider engaged by the
Company for servicing the policies. Likewise the Company may make available copies of the proposal form, annexures, reports of any medical
examination laboratory tests or any documents submitted by me(or, as the case may be, by my beneficiary) or procured by the Company to any
insurer to any claims investigator or any service provider engaged by the Company for servicing the policies. So also the Company may without
any reference tome (or, as the case may be, to my beneficiary) furnish to any court / tribunal or other authority any such information or proposal,
annexure, reports or documents as may be required of the Company or as may be considered necessary by the Company.
9. I will abide by Company’s directions on medicals through any medium. The Company or Company’s representative/s may contact me/ us at
the address provided in the proposal form

I declare that should any statement(s) including health declaration be incomplete, false, wrong or inaccurate, or should there be any omission(s)
or withholding of information on my/our part, the company shall have the right to cancel the policy. The Policy will be cancelled immediately by
paying the surrender value, subject to the fraud or misrepresentation being established by the company in accordance with Section 45 of the
Insurance Act, 1938 as amended from time to time

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 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 subsection if at the time of such acceptance the insurance agent satisfies the prescribed conditions
establishing that he is a bona fide insurance agent employed by the insurer
2 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

Policy shall not be called in question on the ground of mis-statement after three years Provisions regarding Policy not being called into question
in terms of Section 45 of the Insurance Act, 1938, as amended from time to time. 1. No Policy of Life Insurance shall be called in question on any
ground whatsoever after expiry of 3 yrs from
a) the date of issuance of Policy or
b) the date of commencement of risk or
c) the date of revival of Policy or
d) the date of rider to the Policy whichever is later.
2. On the ground of fraud, a Policy of Life Insurance may be called in question within 3 years from
a) the date of issuance of Policy or
b) the date of commencement of risk or
c) the date of revival of Policy or
d) the date of rider to the Policy whichever is later For this the insurer should communicate in writing to the insured or legal representative or
nominee or assignees of insured, as applicable, mentioning the ground and materials on which such decision is based.
3. Fraud means any of the following acts committed by insured or by his agent, with the intent to deceive the insurer or to induce the insurer to
issue a life insurance Policy:
a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
b) The active concealment of a fact by the insured having knowledge or belief of the fact;
c) Any other act fitted to deceive; and
d) Any such act or omission as the law specifically declares to be fraudulent.
4. Mere silence is not fraud unless, depending on circumstances of the case, it is the duty of the insured or his agent keeping silence to speak or
silence is in itself equivalent to speak.
5. No Insurer shall repudiate a life insurance Policy on the ground of Fraud, if the Insured / beneficiary can prove that the misstatement was true
to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material
fact are within the knowledge of the insurer. Onus of disproving is upon the Policyholder, if alive, or beneficiaries.
6. Life insurance Policy can be called in question within 3 years on the ground that any statement of or suppression of a fact material to
expectancy of life of the insured was incorrectly made in the proposal or other document basis which Policy was issued or revived or rider
issued. For this, the insurer should communicate in writing to the insured or legal representative or nominee or assignees of insured, as
applicable, mentioning the ground and materials on which decision to repudiate the Policy of life insurance is based.
7. In case repudiation is on ground of mis-statement and not on fraud, the premium collected on Policy till the date of repudiation shall be paid to
the insured or legal representative or nominee or assignees of insured, within a period of 90 days from the date of repudiation.
8. Fact shall not be considered material unless it has a direct bearing on the risk undertaken by the insurer. The onus is on insurer to show that if
the insurer had been aware of the said fact, no life insurance Policy would have been issued to the insured.
9. The insurer can call 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 of age of life insured. So, this Section will not be applicable for questioning
age or adjustment based on proof of age submitted subsequently.

Disclaimer

Premium Payment Disclaimer

Please note that the on-line payment made is not from the Bharti AXA Life Insurance Co. Ltd server and that you are getting directed to a
Payment Gateway website. Bharti AXA Life Insurance Co. Ltd. shall have no liability or responsibility for and disclaims all warranties whatsoever,
expressed or implied, relating to the site, including without limitation any warranties related to performance, security, stability, or non-infringement
of the title of the site (including the site content) or any controls downloaded from the site.
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.
Please check your card limit or net banking limit with your bank before using the card/net banking facility for an on-line payment.
The payment would be accepted in INR only.
Proposer should use only his/her credit/ debit card or Internet banking account for payment.