Professional Documents
Culture Documents
In This Policy, The Investment Risk in Investment Portfolio Is Borne by The Policyholder
In This Policy, The Investment Risk in Investment Portfolio Is Borne by The Policyholder
UIN: 142L025V01
POLICY DOCUMENT
Corporate Agent Name: Union Bank of India
CIE Name: Mr.Kishore N. Makhijani
Specified Person Name: Nikhil Soni
Specified Person Code: 80001624
Specified Person Contact No.: 9685591234/
Specified Person Email ID: nikhillsoni@yahoo.co.in
In this policy, the investment risk in investment portfolio is borne by the policyholder.
The Proposer and/or the Life Assured named in the Schedule of this Policy having submitted a proposal together
with a Personal Statement and Declaration and the first installment of premium specified in the Schedule to the
STAR UNION DAI-ICHI LIFE INSURANCE COMPANY LIMITED [the “Company” which expression shall include
its assigns and successors] for grant of the benefits specified in the Schedule, it is agreed by the Company and
the Proposer and/or the Life Assured (the “Parties”) that the proposal, the Personal Statement and the Declaration
together with any report or other document leading to the issue of this Policy shall form the basis of this contract
of assurance do hereby further agree that in consideration of the receipt of future premiums as stated in the
Schedule, the Company will pay such benefits [without interest] as herein stated, to the Beneficiary, on submission
of proof to the complete satisfaction of the Company of the benefits under the Policy having become payable in
accordance with the terms and conditions hereof and of the Beneficiary’s entitlement to them. It is further agreed
by and between the Parties that any endorsement executed either on the Policy itself or through a separate
instrument by the Company and any special provisions subject to which this Policy has been issued and any
Annexures and Addendums hereto shall together form part of the Policy. It is also agreed that this Policy shall be
governed by the laws of India in force from time to time and all premiums and benefits shall be payable in Indian
Rupees only. The benefits attached to and the Premiums [including the Rider premiums if applicable] payable
under this Policy will be subject to taxes and other statutory levies as may be applicable from time to time, and
such taxes, levies etc will be recovered, directly and completely from the Policyholder.
SCHEDULE I
Policy Number: 00551175
Name of the Proposer: Mr Aashutosh Kumar Upadhyay
Name and Address of the Mr Aashutosh Kumar Upadhyay
Life Assured: Vill Post Sonauri
Tehsil Teonthar
Rewa
Madhya Pradesh-486226
Expiry of the
Premium
Nature of the Benefit Sum Assured Term Term / Maturity
Payment Term
Date
Dhan Suraksha Prm 3 - S 125,000.00 10 N.A 10/10/2022
Investment Options:
Allocation of Regular/Limited/Single Premiums: Effective Date:10/10/2012
The Regular/Limited/Single Premiums received, after deduction of applicable Premium Allocation Charges and
Mortality Charges (and Extra Mortality Charges, if any), are utilised to purchase Units in the relevant Funds as per
the percentages indicated below.
Benefits are payable to: The Policy holder , the assignee where a valid assignment / transfer has been recorded
(in accordance with Section 38 of the Insurance Act 1938), or in the event of death of the Life Assured, the
nominee where a valid nomination has been registered (in accordance with section 39 of the Insurance Act 1938),
with the Company, or in the event of death of the Life Assured where there is no valid nomination, the Executors,
Administrators or other legal representatives of the Policyholder, or to such person as directed by a court of
competent jurisdiction in India (the person/s to whom the benefits are payable under this Policy are herein referred
to as the “Beneficiary”). The benefits payable are limited at all times to the monies payable under this Policy.
The Company will pay the appropriate benefits (without interest) as herein stated, to the Beneficiary on proof to the
complete satisfaction of the Company, in its sole discretion, of the benefits under thePolicy having become
payable and of the right of the Beneficiary to the benefits.
Special Provisions (if any) : N.A.
Signed for and on behalf of Star Union Dai-ichi Life Insurance Company Limited
Mumbai, 10/10/2012
Authorised Signatory
The Stamp Duty of Rs 25.00 (Rupees Twenty Five Only) paid by pay order, vide receipt no 14668 dated
27/07/2012.
Version: 1.0
First Premium Receipt
We acknowledge receipt of Rs. 100,000.00/- as deposit towards your proposal for life assurance. The money deposited by
you has been adjusted towards first premium / single premium under this policy, as per the details shown below.
Yours Sincerely,
Note:
_____________________________________________________________________________________________________
_________
Regd Office: Star House 3rd Floor, (West wing), C-5, ‘G’ Block, Bandra-Kurla Complex, Bandra (East), Mumbai – 400 051.
FUND VALUE STATEMENT
SUMMARY OF INVESTMENTS
Transaction Summary
Charges Deducted
Premium Amount : Rs. 100,000.00 Mortality Charges : Rs. 11.69
Premium Allocation Charges : Rs. 5,000.00 Policy Administration Charges : Rs. 25.00
In any case, the policy shall stand cancelled in case of non-encasement of the first premium deposit.
This is as authenticated Receipt/Intimation/Statement In case of any discrepancies, Kindly notify us within 14 working days.