igyk uke

e/; dk uke miuke

igyk uke

e/; dk uke miuke

iwjk uke : ikfylh ds izek.k&i= ij vkidk uke bl rjg fn[ksxk A uke ds izR;sd Hkkx ds chp txg NksM+saA

'kh"kZd : Jh@Jherh@lqJh@MkW-igyk uke

e/; dk uke

miuke Q+ksVks yxk,¡

igyk uke (;fn fookfgr efgyk dk thou chek djuk gks)

'kh"kZd : lqJh@MkW-

tUe frfFkÇyx

frfFk ekg o"kZ

iq#"k

efgyk

vfookfgr

fo/kok ¼fo/kqj½

fookfgr

rykd'kqnk 3 ls vf/kd

cPpksa dh la[;k

jk"Vªh;rk& Hkkjrh; fons'kh ukxfjd Hkkjrh; ewy ds O;fä jk"Vªh;rk crk,¡

oSokfgd fLFkfr

'kh"kZd : Jh@MkW-firk dk uke

��तावक को पॉ�लसी के �ववरण से स�त�ट होना चा�हए और उसे पॉ�लसी क� �मख �वशषेताओ ंक� �ववर�णका म� पर �वशषे �यान देना चा�हए। ु ु

पण � �कए गए ��ताव क� कंपनी �वारा �ाि�त तथा आरं�भक भगतान से ,कंपनी क� ओर से बीमा कराने क� कोई जो�खम क� िज़�मेदार� नह�ं बनती है,तथा कंपनी तब तक िज�मेदार नह�ं होगी जब तक इसने ू ु

जो�खम का बीमा न करा �कया हो तथा पॉ�लसी जार� न कर द� हो।

;wfuVsa ml fnu vkcafVr dh tk,¡xh ftl fnu izLrko iwjs dj fy, tkrs gSa vkSj izhfe;e ds izfr vkosnu jkf'k dk lek;kstu djrs gq, ikfylh esa ifj.kkfer gksrk gS ¼;wfyi ikfylh ds fy, ykxw½

इस ��ताव के साथ आराम�भक रा�श अव�य होनी चा�हए और इसे �कसी भी शाखा म� नकद अथवा अ�ववा लाइफ इ�योर�स अकाउंट �पोज़ल नंबर “...........” को देय चेक अथवा �डमांड �ा�ट अथवा कंपनी �वारा

�वीकत अ�य तर�के से जमा �कया जा सकता है। ृ

नकद रा�श जमा �कए जाने क� ि�थ�त म�, लौटाई जाने वाल� रा�श (य�द कोई हो) का भगतान चेक �वारा ह� �कया जाएगा। ु

chek vf/kfu;e] 1938] le;≤ ij ;Fkk la'kksf/kr] dh /kkjk 45 ds vuqlkj] izLrkodrkZ dks iwjh vkSj lVhd tkudkjh nsuk vko';d gS rkfd daiuh bl izLrko ij gkehnkjh ns lds A

आय का �माण अ�नवाय � है।ु

izLrko QkeZ esa ;fn dksbZ lq/kkj@mifjys[k@L;kgh cnyko fd;k x;k gS] rks ,slh txg ij izfrgLrk{kj djsa Alykgdkj daiuh ds fy, vk'kf;r udn@/kkjd pSd dks izkIr djus ds fy, izkf/k—r ugha gSa A;fn ikfylh ds tkjh djus ls igys gh izLrkodrkZ izLrko dks okil ysrs gSa] rks daiuh izLrkodrkZ dh fpfdRlk tk¡p] ;fn ykxw gks] ij mixr O;; dh dVkSrh djus ds ckn mls vkosnu jkf'k okil dj nsxh A;fn dksbZ fo'ks"k Hkkx vkids fy, ykxw ugha gksrk gS rks —i;k "ykxw ugha" ;k "_" fy[ksa vkSj izLrko QkeZ iwjk Hkjsa A vohok lR;kiu ds mÌs'; ls vkils laidZ djsxh tks vkids laidZ C;kSjs dh tk¡p djus dk vk/kkj gksxk A,u,oh ØsfMV dh rkjh[k@gkehnkjh dh rkjh[k@lR;kiu dh rkjh[k] buesa ls tks Hkh ckn esa gks] gksxk AvuqykHk fun'kZu bl vkosnu dk vfHkUUk Hkkx gS A ikfylh/kkjd dks bl ij gLrk{kj djuk vko';d gS AjkbMj vfuok;Z ugha gSa vkSj vfrfjä ykxr ij miyC/k gSaA

Ver 3.8

(Applicable For Ulip Policy)

In accordance with Section 45 of the Insurance Act 1938, as amended from time to time, the proposer is required to give full and accurate information to enable the Company underwrite this proposal.

Advisor

Advisor

(APPLICABLE FOR ULIP POLICY)

;wfuV ÇyDM Iyku esa] fuos'k iksVZQksfy;ks esa fuos'k dk tksf[ke ikfylh /kkjd }kjk ogu fd;k tkrk gS ¼;wfyi ikfylh ds fy, ykxw ½

dsoy dk;kZy;hu iz;ksx gsrq xzkgd vkbZMh ikfylh la[;k

��ताव la[;k

सलाहकार dk uke

सलाहकार क� सं�या

orZeku xzkgd ds fy,

lkÖksnkj cSad

cSad ,';ksjsal pSuy ds fy, dsoy

lsDVj 'kgjh xzkeh.k lkekftd ,uvkbZ mRikn dk uke

xkao dk fof'k"V dksM

��ाव जमा करने का �ौरा okmpj la[;k

pSd @ MhMh la[;k

jkf'k olwy fd;k x;kLVkQ ,p,uvkbZ

izLrko QkeZ

�ट�प�णयाँ:-

igyk thou] ftldk chek fd;k tkuk gS] ds fooj.k (—i;k dsoy Li"V v{kjksa esa Hkjsa)

cSad 'kk[kk dksM

xzkgd [kaM ,lih izek.k&i= la-

Specimen only- Not valid for application

irk(tgk¡ t+:jh gks] ogk¡ ekQZr] lqiq=@

lqiq=h@iRuh@ifr@firk n'kkZ,¡½

ySaMekdZ fiu dksM

'kgj / xkao tyka jkT;

Q+ksu

,lVhMh dksM Q+ksu uacjeksckby

irk

ySaMekdZ fiu dksM

'kgj / xkao tyka jkT;

Q+ksu

,lVhMh dksM Q+ksu uacjeksckby

vkoklh; fLFkfr Hkkjr esa ugha jgus okysHkkjr esa jgus okys fuokl dk ns'k crk,¡

i=kpkj dk irk vkokl LFkkbZdk;kZy;

orZeku vkoklh; irk (—i;k irs ds izR;sd Hkkx ds chp txg NksM+sa½

irk(tgk¡ t+:jh gks] ogk¡ ekQZr] lqiq=@

lqiq=h@iRuh@ifr@firk n'kkZ,¡½

ySaMekdZ fiu dksM

'kgj / xkao tyka jkT;

Q+ksu

,lVhMh dksM Q+ksu uacjeksckby

;fn vki Hkkjrh; gSa ;k Hkkjrh; ewy ds gSa ysfdu Hkkjr esa ugha jgrs gSa] rks —i;k ,uvkjvkbZ iz'ukoyh Hkjsa A

;fn orZeku vkoklh; irs ls vyx gks rks

vkidk inuke

D;k vkids dke esa dksbZ fo'ks"k tksf[ke gS ¼tSls jklk;fud dkj[kkuk] [kku] foLQksVd] la{kkjd jlk;u vkfn½ ;fn gk¡] rks —i;k C;kSjk crk,¡

laxBu @ O;olk; dk uke

chekjf{kr O;fä dh okÆ"kd vk; #- & ;fn dekrs ugha gSa rks jksxh@iRuh ;k ifr dh okÆ"kd vk; #- &

bZesy vkbZMh

vk;q dk izek.k Ldwy@dkWyst dk izek.k i= uxj ikfydk ds vfHkys[k j{kk igpku i= ikj i= vU; ¼mYys[k djsa½

vk; dj ih,,u la[;k

Duration of Course

osruHkksxh O;olk; ds Lokeh Lo&fu;ksftris'kk fo|kFkhZ

x`fg.kh fdlku vU; ¼mYys[k djsa½

LukrdksŸkj Lukrd fMIyksek 12oha mŸkh.kZ 12oha ls de vU; ¼mYys[k djsa½ 'kSf{kd ;ksX;rk

lsokfuo`Ÿk @ isa'kuHkksxh

;fn fo|kFkhZ gSa orZeku esa v/;;ujr ikB~¸kØe ------------------------------------------------------------ (b) laLFkku dk uke (C) ikB~¸kØe dh vof/k

gk¡ ugha

LFkkbZ irk

chek fd, tkus okys O;fä ds dk;Z fooj.k

dk;Z dh Bhd&Bhd iz—fr ooj.k nsa tSls [kk|kUUk@diM+s dk O;kikj] VSDlh pykuk@Mk;e.M fu;kZr dk dkjksckj vkfn

chekjf{kr nwljs O;fä ds fooj.k] ;fn ykxw gksa (कपया केवल �प�ट अ�र� म� भर�)ृ

chek fd, tkus okys O;fä ds dk;Z fooj.k

dk;Z dh Bhd&Bhd iz—fr

vkidk inuke

D;k vkids dke esa dksbZ fo'ks"k tksf[ke gS ¼tSls jklk;fud dkj[kkuk] [kku] foLQksVd] la{kkjd jlk;u vkfn½ ;fn gk¡] rks —i;k C;kSjk crk,¡

laxBu @ O;olk; dk uke

chekjf{kr O;fä dh okÆ"kd vk; #- ;fn dekrs ugha gSa rks jksxh@iRuh ;k ifr dh okÆ"kd vk; #-

bZesy vkbZMh

gk¡ ugha

ySaMekdZ fiu dksM

'kgj ftyka jkT;

Q+ksu

Q+ksu ,lVhMh dksM eksckby

irk

vk;q dk izek.k Ldwy@dkWyst dk izek.k i= j{kk igpku i= ikj i= vU; ¼mYys[k djsa½Ldwy@dkWyst dk izek.k i=

iwjk uke : ikfylh ds izek.k&i= ij vkidk uke bl rjg fn[ksxk A uke ds izR;sd Hkkx ds chp txg NksM+saA

'kh"kZd Jh@Jherh@lqJh@MkW- igyk uke

e/; dk uke miuke

'kh"kZd Jh@Jherh@lqJh@MkW- igyk uke

e/; dk uke miuke

'kh"kZd Jh@Jherh@lqJh@MkW- igyk uke

e/; dk uke miuke

igyk uke (;fn fookfgr efgyk dk thou chek djuk gks½

firk dk uke

tUe frfFkÇyx

frfFk ekg o"kZ

iq#"k

efgyk

vfookfgr

fo/kok ¼fo/kqj½

fookfgr

rykd'kqnk 3 ls vf/kd

cPpksa dh la[;k

jk"Vªh;rk Hkkjrh; fons'kh ukxfjd Hkkjrh; ewy ds O;fä jk"Vªh;rk crk,¡

oSokfgd fLFkfr

vkoklh; fLFkfr Hkkjr esa ugha jgus okysHkkjr esa jgus okys fuokl dk ns'k crk,¡2.9

Duration of Course

osruHkksxh O;olk; ds Lokeh Lo&fu;ksftris'kk fo|kFkhZ

x`fg.kh fdlku vU; ¼mYys[k djsa½

LukrdksŸkj Lukrd fMIyksek 12oha mŸkh.kZ 12oha ls de vU; ¼mYys[k djsa½ 'kSf{kd ;ksX;rk

lsokfuo`Ÿk @ isa'kuHkksxh

;fn fo|kFkhZ gSa orZeku esa v/;;ujr ikB~¸kØe ------------------------------------------------------------ (b) laLFkku dk uke (C) ikB~¸kØe dh vof/k

Phone No.

izLrkodrkZ ds fooj.k (;fn chekjf{kr O;fä ls vyx gks½

fLFkfr O;fä ,p;w,Q lkÖksnkjh dkiksZjsV U;kl ljdkjh fudk;

izLrkodrkZ dk iwjk uke

Q+ksVks yxk,¡

miuke

miuke

e/; dk uke

e/; dk uke

'kh"kZd Jh@Jherh@lqJh@MkW-igyk uke

'kh"kZd Jh@Jherh@lqJh@MkW-igyk uke

firk dk uke

izLrkodrkZ ds fooj.kD;k vkids uke dksbZ chek ikfylh gS

dqy okÆ"kd izhfe;e¼ #- vadksa esa½

izLrkodrkZ ds dk;Z laca/kh fooj.k

bZesy vkbZMh

izLrkodrkZ dk irkikfylh ds izek.k&i= ij vkidk uke bl rjg fn[ksxk A uke ds izR;sd Hkkx ds chp txg NksM+saA

bZesy vkbZMh

D;k vkids dke esa dksbZ fo'ks"k tksf[ke gS ¼tSls jklk;fud dkj[kkuk] [kku] foLQksVd] la{kkjd jlk;u vkfn½;fn gk¡] rks —i;k C;kSjk crk,¡

okÆ"kd vk; #-

;fn vki Hkkjrh; gSa ;k Hkkjrh; ewy ds gSa ysfdu Hkkjr esa ugha jgrs gSa] rks —i;k ,uvkjvkbZ iz'ukoyh Hkjsa A

tUe frfFkÇyx

frfFkekg o"kZ

iq#"k

efgyk

vfookfgr

fo/kok ¼fo/kqj½

fookfgr

rykd'kqnk 3 ls vf/kd

cPpksa dh la[;k

jk"Vªh;rk& Hkkjrh; fons'kh ukxfjd Hkkjrh; ewy ds O;fä jk"Vªh;rk crk,¡

oSokfgd fLFkfr

vkoklh; fLFkfr Hkkjr esa ugha jgus okysHkkjr esa jgus okys fuokl dk ns'k crk,¡

ySaMekdZ fiu dksM

'kgj ftyka jkT;

Q+ksu

,lVhMh dksM Q+ksu uacjeksckby

irk

ySaMekdZ fiu dksM

'kgj ftyka jkT;

Q+ksu

,lVhMh dksM Q+ksu uacjeksckby

irk

gk¡

gk¡

ugha

ugha

dk;Z dh Bhd&Bhd iz—fr

vkidk inuke

laxBu @ O;olk; dk uke

D;k vki fdlh nwljs O;fä dh thou chek ikfylh ds izhfe;e dk Hkqxrku dj jgs gSa?

;fn gk¡] rks dqy okÆ"kd izhfe;e

rhljk ukferh

(chek vf/kfu;e 1938 dh /kkjk 39 ds rgr½

o"kZ o"kZ

tUe frfFk

ekg ekgfrfFk frfFk

;fn mi;qZä ukferh vkids ekrk firk@iRuh ;k ifr@cPpksa ds vykok dksbZ vU; O;fä gS] rks uhps nh xbZ txg esa ,sls ukekadu dk dkj.k crk,¡ &

¼;fn ukferh vo;Ld gS] rks fu;qä O;fä ds C;kSjs uhps nsa½ (o;Ld gksuk vko';d½

chek jf{kr jkf'k ¼;fn ykxw gks½

xzkgd funsZf'kr ¼vadksa esa½

Iyku dh vof/k] o"kks± esa ¼;fn ykxw gks½

Iyku dk uke

vkosnu fd, x, Iyku ds fooj.k

uksV & la;qä O;fä;ksa ds ekeys esa] ;g ukekadu chekjf{kr nksuksa O;fä;ksa dh ,d lkFk e`R;q gksus ;k vafre thfor chekjf{kr O;fä dh e`R;q gksus ij izpkfyr gksxk

fu;qä O;fä ds gLrk{kj

fodYi xfodYi [kfodYi dfodYi pqusa ¼;fn ykxw gks½

/kweziku ugha djrs/kweziku djrs gSaoxZ pqusa ¼;fn ykxw gks½

vf/kdreU;wuredoj dk Lrj ¼;fn ykxw gks½

pquk x;k jkbMj

jkbMj

vohok nq?kZVuktU; e`R;q fgrykHk

chek jf{kr jkf'k

vohok O;kid LokLF; fgrykHk

vohok nq?kZVuktU; e`R;q vkSj vaxPNsnu

vohok gsYFk xkMZ jkbMj vohok cky f'k{kk jkbMj

vk;@ifjokj dh vk; fgrykHk jkbMjvohok VeZ@VeZ Iyl jkbMj

vohok Hk;kud chekjh

ukekadu dk C;kSjk (;fn chekjf{kr O;fä vkSj izLrkodrkZ ,d gks rks Hkjsa½

ukferh dk uke igyk ukferh nwljk ukferh

tUe frfFk

irk

izhfe;e Hkqxrku djus dh vof/k] o"kks± esa ¼;fn ykxw gks½

okÆ"kd izhfe;e #- esa ¼;fn ykxw gks½

vk;q dk izek.k uxj ikfydk ds vfHkys[k j{kk igpku i= ikj i= vU; ¼mYys[k djsa½Ldwy@dkWyst dk izek.k i=

gk¡ ugha

vk; dj ih,,u la[;k

gdnkfjrk dk izfr'kr

बीमा रि�त ��� से संबंध

ÃÅñîÔÆéÅqwrI^

o"kZekgfrfFk

irk

jkbMj chek jf{kr jkf'k

Dynamic P/E Fund

lwphdj.k fodYi ¼;fn ykxw gks½

bZlh,l

Lopkfyr ifjlaifŸk vkcaVu*¼;fn ykxw gks½

vko`fŸk ds vuqlkj izhfe;e ¼#- esa½

okÆ"kd v/kZokÆ"kd ,d izhfe;eekfldizhfe;e dh vko`fŸk frekgh

ØsfMV dkMZनकद िडमांड ड� ा� Mk;jsDV MsfcV

baMsDl QaM & IIMk;ufed ih@bZ QaM

bZMhlh

LokLF; ,oa dk;Zdyki Hkkx

;fn vki Lopkfyr ifjlaifŸk vkcaVu Iyku pqurs gSa] rks vkidks vius izhfe;e dks mi;qä QaM ds chp gh vkcafVr djuk gksxk

QaM ds izdkj ¼;fn ykxw gks½

xzksFk QaM & IIizksVsDVj QaM & IIcSysaLM QaM & II

ih,l;w QaM

—i;k izR;sd ;wfuV ÇyDM QaM esa vki ftruk fuos'k djuk pkgrs gSa] mlds izhfe;e dk izfr'kr crk,¡ ¼dqy 100% gksuk pkfg,½ A izR;sd p;fur QaM esa U;wure vkcaVu 10% gksuk pkfg, A

lkIrkfgd;fn gk¡flLVesfVd VªkalQj Iyku ¼;fn ykxw gks½

bUÝkLVªDpj QaMckaM QaM & II,UgSalj QaM & II

;fn iz'u d, [k, x (II) vkSj ?k ¼ii), ³] p] N ¼iii) ds fy, vkidk mŸkj gk¡ gS] rks uhps fn, x, Vscy esa vfrfjä tkudkjh iznku djsa A uhps nh xbZ tkudkjh ls gesa vkids izLrko ijfcuk fdlh nsjh ds vfrfjä iz'u iwNus esa lqfo/kk gksxh A

चेकHkqxrku dk ojh; ek/;eMsfcV@ØsfMV dkMZ izLrkodrkZ ds uke ij gksus pkfg,

advisor

D;k vkids uke ij cSad [kkrk gS

yackbZ ¼lsa-eh- esa½

D;k vki ikfylh dh rkjh[k ihNs djuk pkgrs gSa

Cpr [kkrk

dsoy ikjaifjd mRiknksa ds fy,

Pkkyw [kkrk

;fn gk¡] rks cSad ds fooj.k nsa (Mk;jsDV MsfcV@ØsfMV dkMZ@bZlh,l ds ekeys esa vfuok;Z½

[kkrs dk izdkj

cSad [kkrk la[;k

ØsfMV dkMZ la[;k

cSad dk uke

;fn gk¡] rks 'kq# djus dh rkjh[k (pkyw foŸkh; o"kZ esa½

chekj{kk fd, tkus okys O;fä dk ifjokj vkSj futh fooj.k

futh fooj.k

igyk O;fä nwljk O;fä

maph otu

ot+u ¼fd-xzk- esa½

D;k fiNys 1 o"kZ esa vkidh ot+u esa 5 fd-xzk- ls vf/kd dk ifjorZu gqvk gS

mldk dkj.k

ekfld

,uvkjvks@,uvkjbZ

o"kZekgfrfFk

?kVk c

D;k vki /kweziku djrs gSa ;k flxkj] flxjsV] chM+h ;k rackdw;qä dksbZ vU; mRikn ¼iku elkyk vkfn½ dk lsou djrs gSa ;k dHkh fd;k gS

ܶÕð Ô» å» ÇÕðêÅ ÕðÕ¶ âðµ× ç¶ éÅî Áå¶ ô°ðÈ Õðé çÆ Áå¶ Ûµâ¶ ÜÅä çÆ ÇîåÆ ÃÇÔå êÈðé ò¶ðò¶ êÌçÅé Õð¯Í

First Life Second Life

dc ls

;fn gk¡] rks vki fnu esa fdruh flxjsV@flxkj@chM+h @ rackdw dk lsou djrs gSa

ÕÆ å°Ãƺ ÕçÆ ÇÃ×ðà / å¿ìÅÕÈ ç¶ Ã¶òé ù صà Õðé / êðÔ¶÷ Õðé ñÂÆ âÅÕàðÆ ÃñÅÔ çÆ î¿× ÕÆåÆ Ü» ñÂÆ ÔË?

ôðÅì

ÕÆ å°Ãƺ ÕçÆ ôðÅì çŠöòé ÕÆåÅ Ü» êÆåÆ ÔË?

ܶÕð Ô», å» êÌåÆ ÔëåÅ å°Ãƺ ôðÅì çÆ ÇÕ¿éÆ îÅåðÅ êÆºç¶ Ô¯? (A ÇÂÕÅÂÆ =A/B ì¯åñ ìÆÁð / A ×ñÅà òÅÂÆé/ A êËµ× îÅê ÃÇêÌ¿à)

ÇÕ¿é¶ Ã 寺

ÕÆ å°Ãƺ ÕçÆ ôðÅì êÆä çÆ îÅåðÅ ù صà Õðé Ü» êðÔ¶÷ Õðé ñÂÆ âÅÕàðÆ ÃñÅÔ çÆ î¿× ÕÆåÆ Ü» ñÂÆ ÔË?

âðµ× (çòÅÂÆ) çÆ ç°ðòð寺

ÕÆ å°Ãƺ Ô°ä Ü» ÕçÆ òÆ êÇÔñ» À°ÇÚå âÅÕàðÆ Çé×ðÅéÆ ç¶ ÁèÆé âÅÕàðÆ ÔÅñÅå ç¶ ÇÂñÅÜ ñÂÆ Ô¯ð ÇÕö òÆ åð·» çÆÁ» âðµ× ÇÜò¶º ÇÕ Á˺ø¶à¶îÅÂÆéÃ, ìÅðÇìàÈð¶àÃ, í¿×, Õ¯Õ¶é, ÔÅñ°ÕÆé¯Ü¶éÃ, Üó·ÆÁ»-ìÈàÆÁ», ÁëÆî ÇîÇñÁÅ éôÅ, çðç ÔàÅÀ°ä òÅñÆ çòÅÂÆ, دñ ÁÅÇç çÆ òð寺 Õð ðÔ¶ Ô¯ Ü» ÕÆåÆ ÔËÍ

v.

vi.

vii.

viii.

ix.

x.

xi.

xii.

xiii.

xiv.

xv.

xvi.

iv.

iii.

First Life Second Life

A. Are you currently receiving any medical treatment or are you awaiting medical or surgical consultation, test or investigation? (You need not disclose matters relating to uncomplicated pregnancy, common colds, influenza,hay-fever or any minor ailment requiring a single consultation)

i.

ii.

kI qusIN mOjUdw koeI fwktrI ielwj lY rhy ho jW kI qusIN fwktrI jW srjIkl slwh, jW pVqwl dw ieMqzwr kr rhy ho? quhwnUM sDwrn

grBkwl, Awm zukwm, nzlw, prwg-buKwr jW isr& slwh-mSvry vwly Coty-moty rog sMbMDI mwmly dw Kulwsw krn dI loV nhIN hY[

B. Have you ever had any medical or surgical treatment, including investigations, tests, scans or X-Ray for anyof the following illnesses or medical conditions:

kI qusIN kdI vI hyT ilKI ibmwrI jW fwktrI hwlwq leI pVqwl, jWc, skYn jW AYks-ry sihq fwktrI jW srjIkl ielwj ilAw hY:

High blood pressure, angina, heart attack, stroke or any other disorder of heart or circulation?au~c rkq dbwA, gly dy rog, idl dw dOrw, dorw jW idl dI koeI vI AivvsQw jW dOrw?

Any form of cancer, tumor or growth?kYNsr, rsOlI jW vwDy dI koeI vI iksm?

Disorder of skin or lymph glands?cmVI dI gVbVI jW lsIkw glYNf?

Diabetes, kidney or liver problem?mDumyh, gurdy jW ijgr dI koeI vI sm`isAw?

Colitis or any other stomach, bowel or bladder problem?kulMj jW pyt, pKwnw jW blYfr dI koeI vI sm`isAw?

Mental or nervous illness (including depression) lasting for more than 3 months and/or requiring more than 10 consecutive days off work?3 mhIinAW qoN izAwdw Aqy/jW kMm dy 10 islislyvwr idnW qoN izAwdw mwnisk jW nwVI-pRbMDn dI ibmwrI (audwsIn sihq)

Asthma, bronchitis, pneumonia, TB or any other respiratory or lung disorder?swh, sozS, inmUnIAw, tI.bI. jW swh dI koeI hor ibmwrI jW PyPiVAW dI gVbVI

Ulcer, chronic diarrhoea, hepatitis or jaundice?PoVw, dwiemI dsq, hYpytweIts jW pIlIAw

Congenital disorder, anemia, bleeding or blood disorder?pYdwieSI gVbVI, KUn dI kmI, KUn vihxw jW KUn dI gVbVI?Reproductive organ or prostrate disorder?jxn-AMg jW mUDy lMmy pYx dI gVbVI

Arthritis, gout or joint pain, muscle, bone fracture or disorder?gTIAw jW joVW dw drd, mws-pySIAW, h`fI dw tu`txw jW gVbVI?

AIDS or AIDS related complex or test indicating presence of HIV?eyfs jW eyfz sMbMDI jitlqw jW AY~c. AweI. vI. dI mOjUdgI drswauNdI jWc

Any other illness, surgery or injury?koeI vI hor ibmwrI, srjrI jW s`tDo you have any bodily deformities?kI quhwnUM koeI vI srIrk kurUpqw hY?

Do you have any health symptoms or complaints for which a physician has not been consulted ortreatment received? eg: persistent fever, unexplained weight loss, loss of appetite, pain, swelling etc.?kI quhwnUM koeI vI ishq l`Cx jW iSkwieqW hn ijs leI iksy fwktr leI slwh-mSvrw nhIN kIqw igAw jW ielwj nhIN

ilAw igAw? audhwrx leI: h`TI buKwr, Axjwx Bwr dw Gt jwxw, Bu`K dw Gt jwxw, drd, sozS Awid?

igyk O;fä nwljk O;fä

Multiple sclerosis, epilepsy, tremor, numbness, double vision or giddiness?bhu-sklyrIAs, imrgI, kWbw, suMnqw, do-p`KI idRStI jW Gbrwht hoxI

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

Yes No Yes Nogk¡ gk¡ugha ugha

gk¡ ugha gk¡ ugha

gk¡ ugha gk¡ ugha

gk¡ ugha gk¡ ugha

gk¡ ugha gk¡ ugha

gk¡ ugha gk¡ ugha

igyk O;fä nwljk O;fä

J. Are you or your Nominee a Politically Exposed Person (PEP) ?

Politically Exposed Persons(PEP)are individuals who are or have been entrusted with prominent public functions, for example Heads/Ministers of Central/State government, Senior politicians , Senior government/Judicial /Military officers, Senior Executive of State owned Corporations, important polictical party officials & immdeiate family member of above persons(Spouse, Children, Parents and Siblings, In-laws)

K. If you hold any government card / ID which is specifically issued for economic and financially backward strata of the society like BPL /APL Card, MNREGA Card etc., please give details (please state NA or not applicable, if this is not applicable to you)

L.

D;k vkidks dh LokLF; laca/kh dkj.kksa ls dke ls NqV~Vh ysuh iM+h A

dke ds vykok] D;k lsgr ds dkj.k vkids jkstejkZ ds dkedkt izHkkfor gq, gSa

D;k vki xHkZorh gSa ?

dsoy efgyk thou ds fy, &

fookfgr efgykvksa ds fy,] ifr ds chek laca/kh C;kSjs chekjf{kr jkf'k

D;k vkidks dksbZ óh&jksx Fkk ;k gS

D;k orZeku esa ;k vrhr esa] vkidks xHkZ/kkj.k laca/kh dksbZ ijs'kkfu;k¡ Fkha ;k gSa ?

;fn gk¡] rks xHkZ/kkj.k ds g¶rksa dh la-

;fn vkids ikl dksbZ ljdkjh i=@igpku i= gS ftls lekt ds vkÆFkd rFkk foŸkh; :i ls fiNM+s izkf/kdkjh }kjk tkjh fd;k x;k tSls chih,y@,ih,y dkMZ] eujsxk i= vkfn] —i;k fooj.k nsa

(;fn ;g vkids fy, ykxw ugha gksrk gS rks yk-u- ;k ykxw ugha fy[ksa½

igyk O;fämi;qZä iz'uksa ds mŸkj gk¡ gksus ij laiw.kZ fooj.k nsa] ftlesa fpfdRldh; ifjfLFkfr@chekjh@pksV dh iz—fr] rkjh[k] dkj.k] otg] y{k.k] bykt] ifj.kke] bykt dj jgs MkWDVj dkuke vkSj irk lfgr iwjs C;kSjs gksa

mi;qZä iz'uksa ds mŸkj gk¡ gksus ij laiw.kZ fooj.k nsa] ftlesa fpfdRldh; ifjfLFkfr@chekjh@pksV dh iz—fr] rkjh[k] dkj.k] otg] y{k.k] bykt] ifj.kke] bykt dj jgs MkWDVj dk ukevkSj irk lfgr iwjs C;kSjs gksa

nwljk O;fä

iz'u la-

chek j{kk fd, tkus okys O;fä ds ifjokj ds C;kSjs

iz'u la-

orZeku vk;q

(Vscy dks Hkjus ds fy, mi;qZä vuqPNsn ns[ksa½

;fn thfor gSa

igyk O;fä

ifjtu e`R;q dk dkj.k

;fn e`R;q gks xbZ gS

LokLF; dh gkyr

firk

ekrk

*HkkbZ*cgu ¼cgusa½

e`R;q ds le; vk;q

D;k vkids fo#) dksbZ vkijkf/kd vkjksi yxs@vkijkf/kd dkjZokbZ dh xbZ rFkk@;k orZeku esa blls igys vkids fo#) dksbZ vkijkf/kd vkjksi yafcrFkk ;k gS vFkok vkidks fdlh vkijkf/kd dk;Zokgh esa vijk/kh ekuk x;k rFkk@;k tekur ij jgs@fgjklr esa jgs@fuyafcr ltk gqbZ ?;fn gk¡] rks vkjksi dh rkjh[k] dkj.k vkSj iz—fr lfgr iwjs C;kSjs nsa A

jktuhfrd izHkko okys O;fä ¼ihbZih½ os O;fä gksrs gSa ftUgsa izeq[k lkoZtfud dk;Z ns[krs gSa ;k ftUgsa ,slk dk;Z lkSaik x;k gS] tSls dsUnzh;@jkT; ljdkj ds izeq[k @ ea=h] ofj"B jktusrk] ofj"B ljdkjh@U;kf;d @lSU; vf/kdkjh] jkT; ds LokfeRo okys fuxeksa ds ofj"B dk;Zikyd] egRoiw.kZ jktuhfrd ikVhZ ds inkf/kdkjh vkSj mi;qZä O;fä;ksa ds izR;{k ifjtu ¼iRuh ;k ifr] cPps] ekrk firk vkSj HkkbZ ;k cgu] nkekn ;k cgw½

—i;k chek j{kk fd, tkus okys O;fä ds ifjtuksa ds fooj.k nsa A blds vykok] ;fn ifjtu fny dh chekjh] gªn;k?kkr] mPp jä pki] e/kqesg] fdlh izdkj dh vk¡[k dh chekjh] dSalj] xqnsZ dh chekjh] i{kk?kkr ;k fdlh vkuqokaf'kd@ikfjokfjd chekfj;ksa] fdlh laØked jksx tSls Vhch vkfn ;k fdlh ,slh chekjh ls ihfM+r gSa ;k jgs gSa ;k blds dkj.k e`R;q gqbZ gS tks ;gk¡ mfYyf[kr ugha gS] rks bl ckjs esa uhps fn, x, Vscy esa crk,¡

gk¡ ugha

gk¡ ugha

gk¡ ugha

gk¡ ugha gk¡ ugha

gk¡ ugha

gk¡ ugha

gk¡ ugha

gk¡ ugha

gk¡ ugha

gk¡ ugha

D;k vkidk QSfeyh MkWDVj gS (QSfeyh MkWDVj og gksrs gSa tks fpfdRldh; chekfj;ksa ds fy, fu;fer :i ls lykg nsrs gSa ;k ftuls lykg fy;k tkrk gS½

;fn gk¡] rks QSfeyh MkWDVj ds fooj.k nsa

;fn gk¡] rks QSfeyh MkWDVj ds fooj.k nsa

'kkSd@;k=k ds fooj.k

D;k vki fdlh eksVj LiksVZ] p

NksVh chekfj;ksa ds vykok] D;k vkius viuh tfVy chekjh ;k LokLF; ikfylh ij dksbZ nkok fd;k gS ftlds fy, vkidks iwjh jkf'k feyh

D;k thou] LokLF; ;k tfVy chekjh ds fy, vkids }kjk cgkyh ds fy, fd, x, izLrko ;k vkosnu dks fo'ks"k 'krks± ij vLohdkj fd;k x;k] LFkfxr fd;k x;k;k Lohdkj fd;k x;k vFkok D;k dHkh vkius vkosnu dks okil fy;k

ifjokj ds chek ds fooj.k ¼;fn chekjf{kr O;fä fo|kFkhZ gS ;k /kuktZu ugha djrk gS] rks bls Hkjk tkuk gS½ fuEufyf[kr tkudkjh dsoy chek j{kk fd, tkus okys O;fä ds laca/k esa vko';d gS] izLrkodrkZ ds laca/k esa ugha A

igyk O;fä nwljk O;fä

daiuh dk uke daiuh dk ukeikfylh la[;k ikfylh la[;kvk'oLr /kujkf'k vk'oLr /kujkf'ktkjh djusdk o"kZ

tkjh djusdk o"kZfLFkfr fLFkfr

firk

ekrk

ifr@iRuh

HkkbZ@cgu

HkkbZ@cgu

HkkbZ@cgu

1 I/We declare and confirm that all the replies to the questions in the proposal, the details furnished in the enclosed questionnaires and the reports of any medical examination are provided to the best of my/our knowledge and I/we have fully understood the nature of the questions and importance of disclosing all material information while answering such questions. I / We are aware that the policy is sourced on the basis of limited health questions and I/ We declare that no material information required by Aviva Life Insurance Company India Limited (hereinafter referred to as “the Company”) to assess the risks on my/our life is withheld with me/us.

2 I/We undertake to notify the Company of any change in the state of health of the life to be insured or as to my/his/her occupation subsequent to the signing of this proposal and before the acceptance of the risk by the Company.

3 I/we also certify that I/we have read and understood the Benefits Illustrations and the sales literature as published by the Company that were handed over to me/us along with this proposal form.

4 I/We hereby authorise the Company to conduct screening/confirmation/reconfirmation of my/our health status through medical examinations which may include Laboratory tests, Cardiac, Radiological investigations and other medical tests including blood tests to detect bacterial/viral/fungal infections. I/We hereby give my/our consent to undergo HIV ½ test by ELISA method. I/We am aware that this tesl is only for screening purpose and not confirmatory for HIV/AIDS. Based on the results of these test, the Company reserves the right to accept, decline or offer alternate terms on my/our proposal for life insurance. I/We understand that these tests are being conducted as per the Company's underwriting policy for assessing my/our risk profile and I/We are hereby giving our consent for the same.

5 In order to enable the Company to assess the risk under this proposal and any time thereafter, I/We hereby authorize the past and present employer(s)/ business associates of mine, my medical practitioner/ hospital/ medical source/ any life and non-life Insurance Company/ organization or Life Insurance Association to release to the Company the records of employment/ business or other details of mine as may be considered relevant for acceptance or otherwise of the proposal.

6 In order to enable the Company to assess the risk under my/our proposal and any time thereafter, solely for the purpose of issuance and administration of the policy resulting from this proposal I/We agree and declare that the Company may without any reference to me/us (or to my/our beneficiary, as the case may be) disclose any information contained in the proposal, the annexure, in the reports of any medical examination / laboratory tests or in the documents submitted by me / or procured by the Company to any other insurer or to any reinsurer, to any claims investigator or any service provider engaged by the Company. Likewise the Company may make available copies of the proposal form, annexures, reports of any medical examination laboratory tests or any documents submitted by me/us (or, as the case may be, by my/our

9. Declaration & Authorization

;fn gk¡] rks —i;k C;kSjk crk,¡

;fn gk¡] rks —i;k C;kSjk crk,¡

;fn gk¡] rks —i;k C;kSjk crk,¡

gk¡ gk¡ugha ugha

gk¡ gk¡ugha ugha

gk¡ gk¡ugha ugha

8 of 9

7 I/ We declare that the deposit towards the first premium and the renewal premium to be paid under the Policy are from legally assessed source of Income. In case the premium is paid from any other account other than my /our own, I/we shall ensure that such payment is permitted under Section 80C/80CCC of the Income Tax Act, 1961. I/We declare that in case I/we are found guilty of any offence relating to Anti Money Laundering law, the Company will be in within the rights to cancel the policy issued pursuant to this proposal & forfeit all the premium.

8 I/ We hereby understand and agree that Fraud or Misrepresentation would be dealt with in accordance with the provisions of Section 45 of Insurance Act, 1938 as amended from time to time.

9 I/We agree and confirm to the use of electronic medium, including email, as a mode for communication from and to the Company.

10 In case, for any reason this proposal has not been filled in by me, I/we hereby declare that the contents of this application for insurance, have been fully explained to me/us & I/we have fully understood the significance of the proposed contract. This proposal form shall be a part of the life insurance policy contract, in case of its acceptance by the Company.

10.

beneficiary) or procured by the Company to any insurer to any claims investigator or any service provider engaged by the Company for servicing the policies. So also the Company may without any reference to me/us (or, as the case may be, to my/our beneficiary) furnish to any court / tribunal or other authority any such information or proposal, annexure, reports or documents as may be required of the Company or as may be considered necessary by the Company.

vkils laidZ djus ds mi;qä le; ij lgh fpºu yxk,¡

igyk O;fä nwljk O;fä

chek j{kk fd, tkus okys O;fä ds gLrk{kj*@vaxwBs dh Nki*

QkeZ Hkjus okys O;fä }kjk ?kks"k.kk (;fn gLrk{kj ns'kh Hkk"kk esa fd;k x;k gS] vaxwBs dh Nki yxkbZ xbZ gS] rFkk @ ;k ;fn izLrko izLrkod }kjk ugha Hkjk x;k gS)

eSa ,rn~}kjk ?kks"k.kk djrk @ djrh gw¡ fd eSaus chek j{kk fd, tkus okys O;fä @ izLrkod dks u, Iyku ds ckjs esa iwjh rjg leÖkk fn;k gS vkSj ;g fd mlus bls vPNh rjg leÖk fy;k gS vkSj eSaus chek j{kk fd, tkus okys O;fä @ izLrkod }kjk fn, x,

mŸkjksa dks lR;fu"Bk ls ntZ fd;k gS A

?kks"k.kk djus okys dk uke vkSj irk -

?kks"k.kk djus okys ds gLrk{kj

gLrfyf[kr ns'kh Hkk"kk esa ?kks"k.kk

lykgdkj @ ,lih ds gLrk{kj chek j{kk fd, tkus okys O;fä @ izLrkod ds gLrk{kj

chek j{kk fd, tkus okys O;fä ds gLrk{kj*@vaxwBs dh Nki*izLrkod ds gLrk{kj @ vaxwBs dh Nki¼;fn chek j{kk fd, tkus O;fä ls vyx O;fä gks½

fnukad LFkkufnukad LFkkufnukad LFkku

?kks"k.kk ,oa izkf/kdj.keSa@ge ;g ?kks"k.kk djrk@djrh gw¡@djrs gSa vkSj ;g laiq"V djrk@djrh gw¡@djrs gSa fd izLrko esa iwNs x, iz'uksa ds lHkh mŸkj] layXu iz'ukoyh esa fn, x, fooj.k vkSj fpfdRlk tk¡p ds fjiksVZ] tgk¡ rd esjh@gekjh tkudkjh gS] iznku fd, x, gSa vkSj eSaus@geus iz'uksa dh iz—fr dks vkSj mä iz'uksa dk mŸkj nsrs le; lHkh egRoiw.kZ tkudkjh dks izdV djus dh egŸkk dks leÖk fy;k gS A eSa@ge bl ckr dks tkurk@tkurh gw¡ @ tkurs gSa fd bl ikfylh dks lhfer LokLF; iz'uksa ds vk/kkj ij fy;k tk jgk gS vkSj eSa@ge ;g ?kks"k.kk djrk@djrh gw¡@djrs gSa fd esjs@gekjs thou dk ewY;kadu djus ds fy, vohok ykbQ ba';ksjsal daiuh bafM;k fyfeVsM ¼ftls ;gk¡ blds ckn "daiuh" dgk x;k gS½ }kjk ,slh fdlh egRoiw.kZ tkudkjh dks ugha fNik;k gS AeSa@ge bl izLrko ij gLrk{kj djus ds QyLo:i rFkk daiuh }kjk tksf[ke dks Lohdkj djus ij] chek j{kk fd, tkus okys O;fä ds LokLF; esa ;k vius@mlds is'ks esa dksbZ ifjorZu gksus ij daiuh dks lwfpr djus dk opu nsrk@nsrh gw¡@nsrs gSa AeSa@ge ;g Hkh izekf.kr djrk@djrh gw¡@djrs gSa fd eSaus @geus bl izLrko QkeZ ds lkFk eqÖks@gesa fn, x, fgrykHk ds mnkgj.kksa rFkk daiuh }kjk izdkf'kr foØ; lkfgR; dks i

41. (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 aninsurance 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 or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables 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 satisfies 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 liable for a penalty which may extend to ten lakh rupees.

45 ¼1½ thou chek uhfr ds fdlh Hkh uhfr ds lEcU/k esa fdlh çdkj dk ç'u fcek ikfylh dh fnukad ls rhu o"kZ ckn fdlh Hkh fLFkrh esa ugha mBk;k tk,xk] vFkkZr] ikfylh ds fuxZr gksus dh frfFk ls ;k tksf[ke dh çkjEHk dh frfFk ls ;k uhfr ds iqu#/nkj dh frfFk ls] ;k ikfylh ds vuqo`/nh ds fnukad ls] tks Hkh ckn esa gksA

¼2½ thou chek uhfr ds fdlh Hkh uhfr ds lEcU/k esa fdlh çdkj dk ç'u chek ikfylh dh fnukad ls rhu o"kZ ds vanj mBk;k tk ldsxk vFkkZr] ikfylh ds fuxZr gksus dh frfFk ls ;k tksf[ke dh çkjEHk dh frfFk ls ;k uhfr ds iq#/nj dh frfFk ls] ;k ikfylh ds vuqo`/nh ds fnukad ls] tks Hkh igys gksA

c'krsZ dh] chek daiuh fyf[kr esa chek—r O;fä ;k chek—r O;fä ds dkuwuh çfrfuf/k] çR;kf'k;ksa ;k leuqnsf'krh dks mä fu.kZ; ds vk/kkj ,oa dkj.k ls voxr djk;sA¼3½ mi&/kkjk ¼„½ esa fdlh ckr ds gksrs gq,] dksbZ chek daiuh fdlh thou chek ikfylh dks /kks[kk/kMh ds vk/kkj ij vLohdkj ugha dj ldrk] ;fn chek—r O;fä ;g fl) dj lds dh v'kq) o.kZu ;k fdlh rF; dk neu mlds tkudkjh esa lR; ,oa lgh ugha gS o tku cw>dj fdlh rF; dks fNikus dh mldh dksbZ ea'kk ugha gS ;k v'kq) o.kZu ;k fdlh rF; dk neu tkudkjh esa ugha gSA¼4½ thou chek uhfr ds fdlh Hkh uhfr ds lEcU/k esa fdlh çdkj dk ç'u chek ikfylh dh fnukad ls rhu o"kZ ds vanj mBk;k tk ldsxk vFkkZr] ikfylh ds fuxZr gksuh ds frfFk ls ;k tksf[ke dh çkjEHk dh frfFk ls ;k uhfr ds iqu#/nkj dh frfFk ls] ;k ikfylh ds vuqo`/nh ds fnukad ls] tks Hkh ckn esa gks] bl vk/kkj ij dh vk;q&laHkkfork ds lEcU/k esa fd;s x, dksbZ dFku ;k fdlh egRoiw.kZ rF; dk neu vlR; :i ls çLrko esa ;k vU; nLrkostks esa fd;s x,] ftlij dh ikfylh tkjh dh x;h ;k iqu#/nkj fd;k x;k ;k jkbMj tkjh dh x;hAc'krsZ dh] chek daiuh fyf[kr esa chek—r O;fdr ;k chek—r O;fä ds dkuwuh çfrfuf/k] çR;kf'k;ksa ;k leuqnsf'krh dks thou chek ikfylh ds vLohdkj djus ls lEcfU/kr vk/kkjks ,oa dkj.kksa ls voxr djk;sA

vkxs] c'krsZ dh] fdlh Hkh ikfylh dks /kks[kk/kMh ds vk/kkj ij ugha] vfirq v'kq) o.kZu ;k fdlh egRoiw.kZ rF; ds neu ds vk/kkj ij vLohdkj djus dh n'kk esa] tks Hkh çhfe;e ikfylh esa ikfylh ds vLohdkj fd;s tkus ds fnukad rd ,df=r fd;s x, gS] dks chek—r O;fä ;k mlds fof/kd çfrfuf/k ;k çR;k'kh ;k leuqnsf'kfr dks vLoh—r djus dh frfFk ls ‹å fnu ds Hkhrj okil djuk gksxkA ¼5½ bl mi&/kkjk esa ,slh dksbZ ckr chek daiuh] tks dh vk;q çek.k ekaxus dh ik= gks] dks vk;q çek.k fdlh Hkh le; ekaxus ls çfrcaf/kr ugha djrh gS ,oa fdlh Hkh ikfylh ij lansg dsoy bl vk/kkj ij djuk dh ikfylh ds 'krsZ vuqorhZ çek.k ij lek;ksftr dh x;h gS fd chfer O;fä dh vk;q çLrko esa vlR; crk;k x;k gSA

/kkjk 45 ds lEiw.kZ ewyikB ds fy;s le; le; ij la”kksf/kr (chek vf/kfu;e, 1938) dks i