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ADITYA BIRLA SUN LIFE INSURANCE COMPANY LIMITED

Customer Declaration Form I E- Appllcatlon Submission
Advisor Code: ~ L.~ '1 S'J
Main Agent Code: _ _ _ _ _ _ _ __
SP Code: _ _ _ _ _ _ _ _ _ __

I/We, 8Nu. . l<vLS>:d2.EST\:\A . request you to process the Appllcatlon noEA02 cn~ 2':t., for product D\G] S>nELD for sum
through the tablet/ laptop of the Insurance Agent
O (in figure) submitted onllne by me/us on http://empoweratease.blrlasunlife.com/eapp
assured \()'o ~ O
of Adltya Birl1 Sun life Insurance Company limited (ABSLI) 'ft/Ms Ne L) t11, '\)\lU,.f y ,
relevant documents/Information shared with me & understood the product features.
I/We confirm that post my meeting with the said Insurance Agent. I/We have read
and authenticate d the E-appllcatlon using One Tlme Password (OTP) received on my registered mobile number to buy this
benefit/sales Illustration. I/We have submitted
product onllne.
helped by the above referred Insurance agent to fill in the details in the E-application
I/We hereby confirm that - I have filled up the e-appllcatlon form on my own and/or
with the Information provided by me/ us. I further understand that besides the policy benefits as specified in the relevant
form In my/ our presence and In accordance
product documents, there are no other benefits attached with this policy.

and Photograph etc.) as applicable for further processing of this E-application. The
I/We are uploading the requisite documents (Age/ Address/Identity/Income proof
uploaded documents have been duly verified by the Insurance agent.

the importance of disclosing all material information to ABSLI while answering such
I/We fully understand the nature of questions Including health related questions and
E-appllcatlon . I acknowledge and confirm that all Information and details that I have stated In the said E-applicatlon are true, accurate, complete and
questions In this
correct to the best of my knowledge and bellef.
by such statements / disclosures of material facts in the same manner and to the
I/We understand and agree that by submitting this E-appllcation. I / We will be bound
extent, as if I/ We have signed and submitted a written proposal for insurance to the ABSLI.
same
to the submitting of this E-application and before the acceptance of risk by the
I/We undertake to notify ABSLI of any change In the Information furnished subsequent
Company.
information submitted or where the Company is not notified of any changes as
I/We understand that any m,.-statement or suppression or non-disclosure of material
the claim or declare the policy void in accordance with Section 45 of the Insurance Act.
mentioned above. the Company reserves right to repudiate
terms on th_is E-application for life insurance.
I/We understand that the Company reserves the right to accept, decline or offer alternate

APPLICABLE TO NRI/PIO/FOREIGN NATIONAL

emanating there from shall be subject to Indian Jurisdiction .
a) This application shall be processed and underwritte n in India and any contract
in accordance with the laws in India without any reference to the conflict of laws
The contract/ policy shall be solely governed and construed
any disputes arising out of the contract/ policy shall be subject to the exclusive jurisdiction of the courts in Mumbai.
principles. Further,
of India.
b) All policy related communica tions shall be sent only to communica tion addresses
or the making of offer or solicitation by anyone in any
c) This document / application does not constitute the distribution of any information
or offer is not Authorized or to any person to whom it is unlawful to distribute such a document or
jurisdiction in which such distribution
make such an offer or solicitation

DECLARATION
I/we am/are In India and reside in country as Indicated in the application
1) I/We hereby declare and confirm that I/We am/are applying for this policy while
form appended hereby.
Insurance policies offered by Aditya Birla Sun Life Insurance Company
2) I/We hereby declare and confirm that I /We am/are allowed to procure/obtain life
Ltd. '•
by laws of any country/jurisdiction to avail life Insurance policies from
3) I/We hereby declare and confirm that 1 /We am/are not prohibited/precluded
insurance company registered In India.
thenticating and (Iii) updating my/our own Aadhar number (s) in
4) I/We hereby provide my/our consent for (i) collecting, storing and usage (ii) validating/au
and PMLA. I/W~ hereby provl~e m~/our consent for sharing/disclose of the
accordance with the Aadhar Act, 2016 (and regulations made there under)
(s) including demographi c information for the purpose of updating the same in my/our policies with my/our PAN.
Aadhar number
be used to confirm my/our identity & verification across all transactions
5) I/We hereby declare and confirm that below .a~it m_y/our signatures, these can

during life cycle of this policy. --------:-:::--~-:-::-- )i~

Signature - • ~r/SP
Signature - Proposer/Primary Life Signature - Life Insured/Secondary Life

A Name _ _ _ _ _ _ _ __ Name NAl...lNI 'buB£Y

Name AN) L )<IJLS >:f&~
.. ' ~

Date & Place _ _ _ _ _ _ _ _ __ Date & Place 08- ,2.,.2,0'2.\ f;,~,'l>A~/111>

•1 confirm havln1 seen & verlfled original ~C documents of the customer

. .
vernacular Declaration (In case applicable)
applied for by me and the contents of the E-Applicatio n form and all other documents incidental
h d d'f f the product
to me by Mr/Ms
I confir~ that t e !erms an co\ I •o~s o Ad'tya Birla Sun Life Insurance Company Ltd., have been fully explained
(relation with proposer/lif e to be insured) i nh- - - - - - - language
to ava1hng the insurance po 1•1cy romf 't • ) · f · 'd d b
, . · (Fu name o w1 ness _ _ _ _ _ _ _ _
been recorded Is as per t e in ormat1on prov1 e Y
. f II d rstood by me I further confirm that the replies in the proposal form have
and same Is u y un e , 1

me and are true and correct. ·

Name & Signature of Witness

h PROPOSER/LIFE to be Insured signing In vernacular language
Signature/Thumb Impression of t e
EAPP/PRODOC/2017 /005

Tower 1, 16"' Floor, Jupiter

. ormerl Blrla Life Insurance Company limited) Registered Office: One lndiabulls Centre
Limited (F y El hi stone Road Mumbai - 400013 . IRDAI reg no 109. CIN : U99999MH2000PLC128110.
Adltya Birla Life Insurance Company •
d 841 senapatl Bapat Marg, P n
Mil 1Compoun • ' www.adltyablrlasunllfelnsurance .com