Professional Documents
Culture Documents
Proposal form
Under Unit Linked Plans, Investment Risk in Investment Portfolio is Borne by the Policy holder
Important guildelines:
1.This form is to be filled by the policy holder. 2. Before filling up the form please read the product literature to understand the features, benefits, terms and conditions of the product.
3. All details are mandatory and should be filled completely including email ID, mobile number, etc. 4. As per IRDA guidelines on Anti Money Laundering (AML), premium receipts by way of cash are restricted to INR 50,000/- per premium payer. If annual premium is equal to or more than INR 1, 00,000/- per policy by any mode of payment, a copy of PAN card along with evidence of source of funds/income (for premium payment) i.e. income proof documents, need to be submitted. 5.The Company reserves the right to call for any additional requirement subject to underwriting. 6. While answering questions in the proposal form and providing any other information in respect of the insurance, the Policyholder must make a full and frank disclosure. If a full and frank disclosure is not made of all material facts, or if any material fact is misrepresented, IndiaFirst has the right to treat the policy that may be granted as void ab initio subject to Sec 45 of the Insurance Act 1938. 7. In case the Life to be Assured and the policy holder are two different individuals, the proposal form shall be signed by both.
1. Life to be assured's personal details Salutation: Name: Gender: Date of birth: Nationality: Marital status: Education: Occupation: Nature Of Duties: Annual Income:
Mr. hgfhdgh dfhgdhdh Male 03/01/1995 Indian Single MBA/Doctor/CA/Professional Professional 5vbn 44565654
Type of proof Address proof Identity proof Age proof Income proof
Document type NA NA NA NA
2. Policy holder's personal details Salutation: Mr. Name: hgfhdgh dfhgdhdh Gender: Male Date of birth: 03/01/1995 Nationality: Indian Marital status: Single Education: MBA/Doctor/CA/Professional Occupation: Professional Nature Of Duties: 5vbn Annual Income: 44565654 3. Premium payer's details Name : hgfhdgh dfhgdhdh Mailing address: 565466
gfhgfjhgfhj gfhgfjfghj Andaman and Nicobar 677435 9865762332 victorpraba@gmail.com
4. Nominee details Name : Miss bnbvnmhbvn bbvnbvnbvnm Date of birth : 16/01/2013 Gender : Female Relationship with life to be assured : Husband[] 5. Plan details Plan name
Policy term
Installment premium
Rs.1439.0
Sum assured
1000000
Premium frquency
Yearly
Debt fund
0%
Equity fund
0%
Value fund
0%
Details of life insurance policies held/proposals applied with life insurance companies(including existing policies with IndiaFirst Life Insurance Co.Ltd.)
1. Have you ever applied for life insurance policies with IndiaFirst Life Insurance Co.Ltd and with other insurers? If yes,please give full details below, with present status and terms of acceptance for all proposals / policies applied
IndiaFirst Life Insurance : Other Insurance : Yes No Sum assured : Sum assured 56536435 Status : Status :
Inforce Inforce
Life style questions and personal medical history of the life to be assured
Height in feet : 5 Weight in Kg's : 57.0 2. Have either of your parents or any brothers or sisters suffered from or died due to any of the following conditions : Heart problems, diabetes, stroke, hypertension, raised cholestrol, cancer or any heridatory disease? If yes, Please give full details. 3. Have you smoked or used any form of tobacco in the past 12 months? If yes, please indicate in which form: 4. Do you consume any form of alcohol? 5. Have you ever suffered from drug/ narcotics or alcohol addiction or been advised by a doctor to reduce your alcohol/ tobacco consumption? 6. Have you taken part, or do you have plans to take part, in any hazardous activity such as ballooning, mountain cycling, motorbike racing, boxing, gliding, diving, horse riding, martial arts, motor racing, mountain climbing, parachuting, sailing, skiing, weight lifting, white water rafting, wrestling and / or flying other than as a fare paying passenger on a licensed service? (you must still answer YES and give details if you take part in a potentially hazardous activity which is not listed). If yes, please provide details in the special questionnaire which your advisor will provide. 7. Are you currently or do you intend to live or travel outside of India for more than 6 months in a financial year? If yes, please provide full details of countries to be visited and the purpose of visit and duration. Y Inches : 11
N N N N
8. Are you currently taking any medication or drugs, other than minor conditions, (e.g. colds and flu), either Y prescribed or not prescribed by a doctor, or have you suffered from any illness, disorder, disability or injury during the past 5 years which has required any form of medical or specialized examination (including chest xrays, gynecological investigations, pap smear, or blood tests), consultation, hospitalization or surgery? 9. Do you have: congenital/birth defects, pain or problems in the back, spine, muscles or joint, arthritis, gout, severe injury or other physical disability and have you been incapable of working/attending the school during the last 2 years for more than 3 consecutive days or are you currently incapable of working/attending school? Please ignore normal pregnancy. 10. Do you suffer from or ever had any medical ailments e.g. diabetes, high blood pressure, cancer, respiratory disease (including asthma), kidney or liver disease, stroke, any blood disorder, heart problems? Y
11. Do you suffer from or ever had any medical ailments e.g. Hepatitis B or C, or tuberculosis, psychiatric disorder, N depression, colitis, or any other stomach problems, thyroid disorders, reproductive organs, HIV AIDS or a related infection. 12. Do you suffer from or ever had any medical ailments e.g. tumor growth, prostrate disorder, disorder of skin or lymph glands, multiple sclerosis, epilepsy, tremor, numbness, double vision or giddiness, speech defect, paralysis? 13. Have you ever been advised/ had a surgery or any medical investigations like X-ray, CT scan, mammogram, pap smear etc? 14. In the last 3 years, have you been treated, are currently undergoing or have been advised for treatment from a doctor or specialist or undergone any cardiological, radiology or pathological tests (excluding routine checkups)? 15. Are you currently pregnant? 16. . N
Y N