Future Guarantee Ulip

IRDA Registration No. 133

Corporate Office: 001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi, Mumbai 400025 In this policy, the investment risk portfolio is borne by the policyholder

Application No. Policy No.

FUTURE GUARANTEE ULIP To be filled by Office : Name of the Contract

Major Life Date of Inward

Inward No. Branch /Unit Code:

HUF

Housewife

Deposit Receipt No.

Deposit Receipt Date

Product Name: Future Guarantee ULIP

Intermediary Type

Agent

Broker

Agent Code :

3

Mall Assurance

Corporate Agent

Please affix Passport size Photograph

Direct

UM/LG Code :

Instruction for Filling this Proposal Form: 1. This form is to be filled in BLOCK LETTERS by the Proposer or by a person authorized by him. In case the Proposer is unable to fill in this form or the form is filled and/or signed in vernacular / has a thumb impression put, then the Declaration printed at the end of this form must be filled and signed by an ENGLISH – knowing declaration. 2. Please answer all questions. Please tick box thus (3) wherever appropriate. If any of the questions are not applicable, please write ‘N.A.’ Strokes/ Dots/ Dashes/ leaving the answer unanswered may lead to the rejection of the proposal. 3. The proposer must authenticate by signing any cancellation or alteration made in this form. 4. The process is advised to avail the facility of nomination, available in the form (Please Refer Q4). 5. Insurance is a contract of utmost good faith, which requires all the material facts to be disclosed to the insurer. In case of any doubt as to whether a fact is material or not , the fact should be disclosed & kindly note that all amounts mentioned in this form are in Indian Rupees only.

1. LIFE to be Insured (To be filled in BLOCK LETTERS only) Mr.

Title

Mrs.

Ms.

2. PROPOSER (if not the LIFE to be Insured)

First Name

First Name

Middle Name

Middle Name

Surname

Surname

Date of Birth

D

Gender

D

M

M

Male Indian

Nationality Qualifications Occupation







Y

Y

Y

Mr.

Title

Y

Date of Birth

Female

Gender

NRI (Country of Residence)

Nationality

D

Under Grad Grad Others ___________

Qualifications

Business Retired Housewife

Service Student Driver

Occupation









Other ___________

M

M

Y

Y

Ms.

Y

Y

Female

Male Indian

SSLC Post Grad.

Professional Agriculturist Armed Forces/ Police

D

Mrs.

NRI (Country of Residence)

SSLC Post Grad.

Under Grad Grad Others ___________

Business Retired Housewife

Service Student Driver

Annual Income Rs.__________________________

Permanent Account No. (PAN)

Permanent Account No. (PAN)

Single

Married

Do you have an existing policy of FGLI : If yes, please quote policy number (any one)

Widow Yes



Divorced No

3. Address for Communication with Proposer Address

Relationship with Life to be Insured Do you have an existing insurance policy : Do you have an existing policy of FGLi : If Yes, please quote policy number (any one)

i)



Other ___________

Annual Income Rs.__________________________

Marital Status

Professional Agriculturist Armed Forces/ Police

Yes Yes

No No

Name & Address of Employer (if any):

ii) Specify the exact nature of your duties:

Landmark

iii) Are you exposed to any special hazard associated with your occupation (e.g. chemical factory, mines, explosives, corrosives, etc.) which may render you susceptible to injuries or illnesses? Yes No

City



State

Age Proof: (Attach a self attested copy)

Pincode Tel No. Residence : STD : Res./Mob : STD : E-Mail Address:

4. Nominee Details ( If Life Assured & Proposer are same) Name

If Yes, please give details

Residential Proof: (Attach a self attested copy)

Date of Birth

D

D

M

M

Y

Y

Y

Y

Relationship with Life Assured: Address

5. Appointee (in case Nominee is Minor) Name Date of Birth

D

D

M

M

Relationship with Life Assured: Address

Y

Y

Y

Y



Employer’s Cert School/College Cert Baptism Cert Domicile Cert Gram Panchayat Cert

Telephone Bill Ration Card Electricity Bill Bank A/C Statement Letter from Recognized Public Authority Others (pls specify)_____________

Income Proof : (Attach a self attested copy)

I.T. Return/Assessment Order Employer’s Cert Others ___________________ (Give Details)

Identity Proof: (Attach a self attested copy)

Driving Licence Passport PAN Card Voter’s Identity Card Letter from Recognized Public Authority or Public Servant verifying the identity & residence Others ______________________

Rural (Population less than 5000)

Signature

Voter’s I.D. Card Driv License Birth Cert PAN Card Passport Others (Pls Specify _____)



Non Rural

1

6. DETAILS OF THE INSURANCE COVER PROPOSED: Fund Composition Sum Assured :

Rs ____________________________/-

Annualized Premium :

Rs.___________________________/-

Percentage (%)

Future Secure (max 25%) Future Income Future Balance

Policy Term (Also Premium Paying Term) ___________________ yrs.

Future Apex Total

7. Payment Details Premium Amount : Rs______________________/- Cash Payment Remitted by

Frequency of Payment





Cheque

Demand Draft



Credit Card



ECS / SI



Credit Card



ECS / SI (Attach Authorization Letter)

Yearly

Cheque / DD drawn on Bank Branch Address Cheque No./DD No. Credit /Debit Card No. Credit Card/ Debit Card Expiry Date:

D D M M Y Y Y Y

Transaction No.

Cheque Salary Deduction Cash Method of Renewal Premium Payment Bank Account Detail for receiving payment from Future Generali India Life Insurance Co. Ltd : Account No. (Proposer) Bank Name Branch

MICR Code

8.1 PERSONAL HEALTH RECORD OF LIFE TO BE ASSURED: (To Be Filled Only For “With Life Cover” Option) Height :

Cms



Weight :

Kg

In the past 6 months, has your body weight changed by more than 5 Kg? If yes, please mention whether lost or gained and how many Kgs.

Yes

No

Lost

; Gained

; Amount ____________ Kgs

Please state Cause of a change in weight_________________________________________________________________________________________________________________ Visible identification mark if any______________________________________________________________________________________________________________________ 8.2 Health details of life to be assured Answer the following as Yes or No A.

Yes

No

Are you suffering from or have you ever suffered from or sought advice or treatment or have been advised to undergo investigation or treatment for: ( Pl tick the relevant description) i. Ulcer, Colitis, Gall Stones, Chronic Diarrhea, Piles, Fistula, Hepatitis A/B/C, Jaundice, Cirrhosis, or other Liver or Pancreas or Digestive Disorders?

ii. Chest Pain, Palpitation, Rheumatic Fever, Stroke, Heart Attack, Heart Murmur, Shortness of Breath, or other Heart Disorders? iii. Asthma, Bronchitis, Chronic Cough, Pneumonia, T.B., or any other respiratory or lung disorders? iv. Any skin disorder (e.g. dermatitis, eczema, Leprosy or psoriasis)? v. Cancer, Tumor, Enlarged Glands or Enlarged Lymph Nodes? vi. Thyroid Disorders or any other hormonal disorders? vii. Anemia, Bleeding, hemophilia, thalassemia or Blood Disorders? viii. Dizzy / Fainting Spells, Epilepsy, Multiple Sclerosis, Tremors, Numbness, Double Vision, Insomnia, Depression, Stress related problems, Paralysis, Nervous or Mental / Emotional Disorders? ix. Urine, Kidney, Bladder, Reproductive Organ, Hydrocele or Prostrate Disorders? x. Arthritis, Gout, Hernia, Joint Pain, Muscle, Bone Fracture or disorders? xi. Disorders of the Eyes, Ears, Nose & Throat? xii. High / Low Blood Pressure? xiii. Diabetes or sugar in the urine? xiv. Congenital or Hereditary disorders or diseases? xv. Alcohol or Drug abuse or dependency? B.

Apart from the medical conditions mentioned above, have you in last five years i) Suffered from any ailment / injury requiring treatment for more than a week?

ii) Undergone or are currently undergoing or advised to undergo any form of medical treatment, investigation or test? iii) Consulted any doctor or other health practitioner except for common cold/influenza lasting less than 7 days ? iv) Ever remained absent from your place of work on medical grounds for 7 consecutive days or more ? 2

C.

Have you ever or are you currently suffering from any defect in sight, hearing or speech, or any physical impairment or disability or abnormality?

D.

Have you or your spouse received medical advise, testing or treatment in connection with sexually transmitted disease or HIV infection, or suffered from prolonged weight loss, Diarrhoea, enlarged glands or have been advised to abstain from donating blood?

E.

Do you have any health symptoms or complaints for which a physician/ homeopath/ ayurvedic /alternative medical advisor has been consulted or treatment received e.g. persistent fever, unexplained weight loss, loss of appetite, pain, swelling etc.?

If you have answered YES to any part of Question 8.2, please complete the table below & attach relevant questionnaire: Illness, Injury or tests

Date Commenced

Type of treatment

Duration of Illness/ injury

Date of last symptoms

Current Condition

Full name and address of doctor or hospital (if any)

In case of major sickness/operation, the special questionnaire, hospital/ doctor’s report has to be submitted. Section 41 of the insurance act, 1938 : (1) No person shall allow or offer to allow either directly or indirectly, as an inducement to any person to take 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 of renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance wit the published prospectuses or table 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 sub-section if at the time of such acceptance the insurance agent satisfiets 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 punishable with fine which may extend to five hundred rupees.

Section 45 of the Insurance Act, 1938 : “No policy of the life insurance effected before the commencement of this act shall after the expiry of two years from the date of commencement of this act and no policy of life insurance effected after the coming into force of this act shall, after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insurer, or in any other document leading to the issue of the policy, was inaccurate of false, unless the insurer shows that such statements was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose; Provided that 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 state in the proposal”

Declaration for signing in Vernacular

Declaration by Life to be Insured I understand and agree that the statements in the proposal will be the basis of the contract between me and Future Generali Life Insurance Co. Ltd. [“The Company”] and that if any statement is untrue or inaccurate or if any of the matter material to this proposal are not disclosed the company may void the contract and all the premium paid will be forfeited to the company. I agree that I will inform the company if between the date of the proposal and the date of the issue of the policy • there is any change in my general health occupation or financial position • any other proposal or application to any other insurance company on my life is declined/postponed or accepted other than standard terms so that the company may consider the terms of acceptance. I understand that if I fail to do so then the company may void the contract and all the premiums paid will be forfeited to the company.

Future Generali Life Insurance Co. Ltd. requires that this proposal is completed by the proposer. If proposer does not read, write / speak English then this proposal may be completed by another person, then such person need to complete this declaration. I have explained the contents of this proposal to the proposer and endeavoured to ensure that the contents have been fully understood. I have accurately recorded the responses to the information sought by the proposal form and I have read the responses back to the Proposer and confirmed that they are correct.

Name of the Declarant : Address

Signature / Thumb Impression of the Proposer

Signature/ Thumb Impression of Life to be assured if other than the proposer Date:

D

D

M

M

Y

Y

Y

Y

Signature of the Declarant Signature of the Witness

Proposer’s Mobile/Telephone Number

The content of this proposal and documents have been fully explained to me and I have fully understood the significance of the proposed contract

Name of witness Address Place



Date

Confidential Report (To be completed by the Advisor after receiving the complete proposal form) I hereby declare that the proposal form has been completely understood by the client and facts disclosed therein are true and correct to the best of my knowledge and belief. I am satisfied with the identity of this client and recommend proposal for acceptance

Signature of the Life to be Insured

Signature of the Proposer

Name of Witness (if different of the Life to be Insured)

Place Signature of advisor

Signature of Sales Manager

Date:

D

D

M

M

Y

Y

Y

Place Y

Date:

D

D

M

M

Y

Y

Y

Y

3