Residence and Travel Questionnaire (UWN023)

for Individual Business

(To be filled by the Proposer/life to be assured)

Proposal Number :

Name of the Proposer / LA :

Date of birth : Age : Years Male/Female

(Please provide responses to all the questions in the space along side)

Please provide details of your current

residency and your residency status
1
including information on length of stay
on visa etc if applicable

Please provide details of your residence and travel during last 5 years ( excluding the
2
holidays of less than 4 weeks)

Country and Frequency

Reason for Duration of
Dates of Stay region of (number of
visiting each stay
residence trips per year)

Please provide details of your future residence and travel intentions during the next 5
3
years ( excluding the holidays of less than 4 weeks)
Country and Frequency
Reason for Duration of
Dates of Stay region of (number of
visiting each stay
residence trips per year)

Please provide brief description of

4 your occupational duties and / or any
other activities you will participate in
whist travelling or residing abroad

SBI Life Insurance Co Ltd : UWN023 Version 1.2 Dt.26thMarch 2022 Page 1 of 2
 Residence and Travel Questionnaire (UWN023)
for Individual Business
(To be filled by the Proposer/life to be assured)

Do you expect to spend majority of

your time in major/large cities? YES / NO
If NO, please provide the names of
town/region and details of your
5
accommodation, availability of
medical facilities and your internal
travel arrangements ( e.g. light
aircraft, boat etc)

Have you undergone any medical YES / NO

treatment or surgery whilst residing
6 abroad?

If YES, please provide details

Please provide any additional

information on your residence and
7
travel which you feel may be helpful in
processing your proposal
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Declaration to be given by the Proposer/Life to be assured
-------------------------------------------------------------------------------------------------------------------------------
I declare that the answers given above are true and to the best of my knowledge and that
I have not withheld any material information that may influence the assessment or
acceptance of this application.

I agree that this form will constitute part of my application for life assurance and that
failure to disclose any material fact known to me may invalidate the contract.

Place :

Date : Signature of Proposer/ Life to be assured

-------------------------------------------------------------------------------------------------------------------------------
Vernacular Declaration in case the Proposer has signed the
questionnaire in vernacular or Proposer is illiterate
-------------------------------------------------------------------------------------------------------------------------------
I hereby declare that I have read out and explained the contents of this questionnaire to the
Proposer in language and that he/she had understood the
same and the answers were truly and correctly recorded.
I have fully explained that this forms part of the contract and if there has been any non-
disclosure of material fact, the policy may be treated as null and void.

Place :

Date : Signature of person making the Declaration

Name of person making declaration :

Address :

SBI Life Insurance Co Ltd : UWN023 Version 1.2 Dt.26thMarch 2022 Page 2 of 2