24-Dec-2019 14:52:19 Application No.

9Z023775

Product Code :
Product Name :_________________________________________________
Plan Option:____________________________________
(For SBI Life - Smart Elite, SBI Life - Smart Power and wherever applicable)

COMMON ULIP PROPOSAL FORM

SBI LIFE INSURANCE COMPANY LTD.
Registered & Corporate Office: Natraj, M. V. Road, & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. IRDA Registration No. 111
Toll Free: 1800 267 9090(Between 9:00 AM & 9:00 PM) | Email: [email protected] | Website: www.sbilife.co.in | CIN: L99999MH2000PLC129113

"IN CASE OF UNIT LINKED INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER"
CHANNEL DETAILS (This section to be filled by Sales Representative):
Is this Proposal sourced through Distance Marketing? Yes No. If Yes, please state the Distance Marketing Mode:_____________________
Agency Broking Corporate Agency (SBG) Corporate Agency (CS) Corporate Agency (Alternate Channel) Direct

Others (Pls Specify) ____________________

_______________ Worksite Code: -

IA/ CIF/ SP Code: IA/ CIF Name: ________________________________________________________

Bank/ Broker/ CA Code: Bank/ Broker/ CA Name: _______________________________________________

Sourcing Branch Code: Sourcing Branch Name: ________________________________________________

For Alternate Channel / Corporate Agency (SBG) Only:

Code 1 : Code 2 : - Code 3 : -

Instructions for filling up Proposal Form

(1).This form is to be filled by the Proposer in BLOCK LETTERS in BLACK INK. In case the Proposer is unable to fill in the form, the person filling in the
form must complete the declaration in vernacular section of this form. (2). Please tick a box where appropriate & all Questions should be answered.
(3). The Proposer must authenticate any cancellation or alterations in this form. (4). Insurance is a contract of utmost good faith, which requires insurer,
Proposer/ Life to be assured to disclose all material facts. In case any doubt as to whether a fact is material or not, the fact should be disclosed. (5). All
documents submitted with this Proposal Form must be self attested by the Proposer. (6). Please attach an extra sheet, where ever additional information is
to be given.
1. ARE YOU AN EXISTING SBI LIFE CUSTOMER? Yes No 2. WHETHER PROPOSAL IS UNDER(please tick relevant option):
If Yes, provide Customer ID/ Policy No.: Employer Employee Scheme HUF NRI
Insurance Advisor’s Own Life State Bank Group Staff
3. SIMULTANEOUS PROPOSALS (IF ANY) If any option is selected, please submit relevant questionnaire/annexure/
supporting documents along with the Proposal Form as applicable
1) Proposal No. :
4. ASSIGNMENT (Not available for Pension Plans)
2) Proposal No. : Do you want to assign this Policy on issuance? Yes No
3) Proposal No. :
If Yes, please submit relevant documents/annexure with the Proposal Form
5. PREFERRED LANGUAGE FOR COMMUNICATION
English Marathi Hindi Bengali Gujarati Oriya Tamil Telugu Malayalam Kannada Punjabi

6. DETAILS OF PROPOSER/ LIFE TO BE ASSURED/HUF KARTA Mr. Ms. Mrs.

First Name : A R A V I N D H A N

Middle Name :

Last Name : B A L A S U B R A M A N I A N

Father's Name :
Maiden Name : (for female proposers only):
Date of Birth : 2 4 0 2 1 9 7 6 (DD/MM/YYYY) Gender: Male Female Nationality:
Passport No. : Date of Issue : (DD/MM/YYYY)

Valid upto : (DD/MM/YYYY) Country of Residence:

FOR OFFICE USE ONLY

STAMP STAMP STAMP STAMP

STAMP STAMP STAMP STAMP

ULIP.ver.14-10/17 PF ENG Please go through the checklist provided at the last page. Page 1 of 8
 24-Dec-2019 14:52:19 Application No. 9Z023775

For Office Use Only

Sr. No. Product Name Product Code
1 SBI Life - Saral Maha Anand 50
2 SBI Life - Smart Scholar 51
3 SBI Life - Smart Elite 53
4 SBI Life - Smart Wealth Assure 55
5 SBI Life - Smart Power Insurance 1C
6 SBI Life - Retire Smart 1H
7 SBI Life - Smart Wealth Builder 1K

10 most important things

you should do before signing the proposal form.

Have you?
Analyzed and ensured that the plan

1 meets your Insurance Needs and

Long Term Financial Goals. 6 Checked the Benefit
Illustration.

2 Checked the plan type.

Is it Market Linked
or Traditional?
7 Confirmed the tenure of
the plan. Made sure it
is appropriate.

Understood the risk factors,

3 terms and conditions of the plan.

Read the sales brochure carefully. 8 Understood the benefits available
under the plan - before and at
Maturity.

4 Checked whether it is a
Single or Regular
Premium Plan.
9 Checked the Lock in
period and applicable
Surrender Charges.

5 Confirmed the Premium

Amount and the Premium
Paying Term.
10 Provided true and complete
information in the
proposal form.

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 24-Dec-2019 14:52:19 Application No. 9Z023775

Age Proof : Driving Licence School/College Cert PAN Card Passport Birth Cert Others (Pls. Specify)_________
Identity Proof : Voters I.D. Card Letter from Recognized Public Authority or Public Servant with Photograph verifying the identity & residence

PAN Card Driving Licence Aadhar Card Passport Others (Pls. Specify)_______________
Qualifications : Illiterate SSC HSSC Under Graduate Graduate Post Graduate
CA / MBA / Medicine / Engineer (tick which ever is applicable) Others (Pls. Specify)________________________
Marital Status : Single Married Divorced Widow/Widower

Occupation : Business Service Professional Self Employed Retired Housewife

Student Agriculturalist Construction Labour Farm Labour Others (Pls. Specify)_________
Defence / Para Military Forces Force Name: _______________________________ Force Number: ___________________

Name & Address of Employer / Business Organisation/

Workplace:

Specify the exact nature of your duties:

Are you exposed to any special hazard associated with your occupation (e.g. chemical factory, mines, explosives, corrosives,
Yes No
combative duties, oil exploration, high sea voyage etc.) which may render you susceptible to injuries or illnesses?
If Yes, please give details __________________________________________________________________________________________________
Are you a “Politically Exposed Person” (PEP) or a close relative of PEP? Yes No
PEPs are individuals who are or have been entrusted with prominent public functions, i.e. heads / ministers of central / state govt., senior politicians, senior govt, judicial or
military officials, senior executives of govt. companies, important political party officials, immediate family member of above persons (would include spouse, parents, siblings,
children, spouse's parents or siblings and close associates of PEPs.)
If No, then in case your PEP status changes in future, you shall inform SBI Life Insurance Co. Ltd. of such a change.
Do you have any history of conviction under any criminal proceedings in India or abroad. Yes No
If Yes, please give details, _________________________________________________________________________________
_______________________________________________________________________________________________________________________
Please indicate whether you or your spouse is working/ retired from State Bank Group Yes No
If YES, please state: Self: PF/ Pension Index/ Employee No.:_________ Spouse: PF/ Pension Index/ Employee No. :__________________
Annual Income : Source of Income:_______________ PAN * :
Income Proof : I. T. Return/ Assessment Order/ Employers Cert Others (Pls. Specify)___________________________________
*Please submit self attested copy of PAN Card or PAN Exemption Form if annualised premium under this proposal is 50,000 or above
Document Submitted : Copy of PAN Form 60/61
If total premium paid by you is
1 lakh and above please submit documents to show the fund source Aadhar No:
Domicile :
Rural (Population less than 5000) Urban (Unique Identification No.)
Communication Address: C/o, W/o,D/o,S/o, other (if any) _________________________________________________
House No. & Bldg/ :
Society Name
Road/Sector & Landmark :
City/ Village & Taluka : District :
State : Pin :
Country : "Tel.No.(Home): S T D P H O N E N O
Mobile No # : Tel.No.(Office): S T D P H O N E N O

Email ID#:

Address Proof: Telephone Bill Ration Card Electricity Bill Bank A/C Statement
Letter from Recognized Public Authority Others (Pls. Specify)__________________________________________
Indian Permanent Address (It is optional and applicable only for NRI) :
House No. & Bldg/ :
Society Name
Road/Sector & Landmark :

City/ Village & Taluka : District :

State : Pin :
Address Proof : Telephone Bill Ration Card Electricity Bill Bank A/C Statement
Letter from Recognized Public Authority Others (Pls. Specify)_______________________________________
7. DETAILS OF MINOR/ LIFE TO BE ASSURED / HUF MEMBER (If different from the Proposer): Mr. Ms. Mrs.

Full Name :

Address :

Date of Birth : Gender: Female Relationship with the Proposer ______________

(DD/MM/YYYY) Male
Age Proof : Driving Licence School/College Cert PAN Card Passport Birth Cert Others (Pls. Specify)________

#Important : Incase you have not, please provide your email id and mobile number to help us serve you better.
ULIP.ver.14-10/17 PF ENG Page 3 of 8
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 24-Dec-2019 14:52:19 Application No. 9Z023775

8. NOMINEE DETAILS: Mr. Ms. Mrs. (Nomination is not applicable for Minor or HUF Member)
Full Name :

Address :

Date of Birth : Gender : Female Relationship with the Proposer _________________

(DD/MM/YYYY) Male
In case of more than one nominee please attach an extra sheet & percentage of entitlement should total to 100%

8.1 APPOINTEE DETAILS: Mr. Ms. Mrs. (Applicable in case Nominee is a Minor)

Full Name :

Address :

Date of Birth : (DD/MM/YYYY) Gender : Female

Male
(Please sign in black Ink only)
Relationship with the Life to be Assured: ______________________ Signature of Appointee: Signature/ Left Hand Thumb Impression
Relationship to the Nominee: _______________________________

9. DETAILS OF THE INSURANCE COVER PROPOSED:

9.1 BASIC PLAN DETAILS
Plan Type : Single Premium Regular Premium Limited Premium Plan Option :_____________________

Premium Frequency$ : Yearly Half-yearly Quarterly Monthly

Objective of taking this policy : Saving Protection Both Others (Pls. Specify)______________
$For Monthly Mode, 3 months Premium to be paid in advance and Renewal Premium Payment is allowed only through ECS, Credit Card, Direct Debit and SI - EFT.

Maturity/Annuity/Any other option: _______________________________ Maturity/Annuity/Any other option Frequency:

Plan/Rider/Option Benefit (Refer respective
Policy Term Premium Paying
Product Sales Brochure for riders/options SAMF Sum Assured ( ) Premium Payable( )
(Yrs.) Term (Yrs.)
applicable)
Basic Plan Name
Rider/Option Name N.A.
Rider/Option Name N.A.
Rider/Option Name N.A.
Rider/Option Name N.A.
Modal Premium Payable ( )

9.2 FUND DETAILS

For SBI Life Product Name Fund Option

Plan Name Fund Options (Allocation % should total to 100 %)

SBI Life - Smart Wealth Builder(1K)

SBI Life - Smart Scholar (51) Equity Fund Bond Fund Equity Optimiser Fund
SBI Life - Smart Power Insurance(1C) Top 300 Fund Growth Fund Money Market Fund
(Smart Funds)
Balanced Fund
____________________________

SBI Life - Saral Maha Anand (50)

Equity Fund Balanced Fund Bond Fund
____________________________

Balanced Fund Bond Fund Equity Elite Fund II

SBI Life - Smart Elite (53)
Money Market Fund

SBI Life - Smart Wealth Assure (55) Equity Fund Bond Fund

SBI Life - Retire Smart (1H) 1 0 0 Advantage Plan

#Important : Incase you have not, please provide your email id and mobile number to help us serve you better.
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 24-Dec-2019 14:52:19 Application No. 9Z023775

9.3 DETAILS OF PREMIUM REMITTANCE^ :

Is deposit for premium under this proposal paid by you ? Yes No (If answer is NO, please provide required information under Point 20 of the proposal form)
If Premium is Remitted through Draft/Cheque, then the same should be issued in favour of 'SBI Life Insurance Co. Ltd.- Proposal Form No. _________________'
Draft/ Cheque No. Date Amount ( ) Drawn on (Bank/ Branch)

If Premium is Remitted by Electronic Fund Transfer (EFT), through State Bank Group (SBG) Branch, Please provide the Details Below :
Bank Name Branch Name Branch Code Date of EFT Customer Amount ( )
A/c Number

^Please note that SBI Life branches and its sales team are not authorised to collect cash from its customers
10. MODE OF PAYMENT OF RENEWAL PREMIUM
Direct Remittance (Cheque/DD) EFT (Available only through SBG Branches ) Online Payment Through SBI Life website (www.sbilife.co.in)
Credit Card ECS (Note: Register for these facilities after receipt of Policy Document)
Standing Instructions (Register with your Bank for this facility and ensure that the bank remits the Renewal Premium to the SBI Life on due dates)
State Bank ATM (For State Bank ATM customers only, register at State Bank ATM on receipt of Policy Document)
SI-EFT (For State Bank Group) Direct Debit
SBI LIFE shall not be responsible for the failure of any of the payment mechanisms, if any. It is the sole responsibility of the Proposer to ensure that the premium is received by SBI LIFE.
11. DO YOU HAVE ANY OTHER INDIVIDUAL LIFE INSURANCE POLICY OR HAVE YOU APPLIED FOR ONE? Yes No (If yes,please provide details below)
Name of Policy / Proposal Year of Product/Plan/ Medical Yearly Sum Assured Self/Spouse/
Insurance Co. No. Issue Rider / Option (Y/N) Premium ( ) ( ) Parent (Pls. specify) Policy Status

Decline Postpone
Rated Up Reject
Inforce Lapsed
Applied Surrendered
Decline Postpone
Rated Up Reject
Inforce Lapsed
Applied Surrendered
Additional sheets with relevant details may be added if space is insufficient
12. FAMILY HISTORY OF THE LIFE TO BE ASSURED:

Alive/ Present Age / Have any of your parents, brothers or sisters died or suffered from any of the diseases /
Relation Not Age at Death disorders specified below ?***
Alive Nature of Disorder*** Particulars, including date of diagnosis. If not alive, specify cause of death.
Father
Mother
Brother(s)
Sister(s)
Spouse
No. of Children Sons( )
Daughters( )
*** Heart disease, Hypertension, High Blood Pressure, Diabetes, Stroke, Cancer, Kidney disease, any Hereditary disease, if any other disease, pls. specify.
13. MEDICAL AND OTHER DETAILS OF THE LIFE TO BE ASSURED:
(Please provide details of Life to be Assured. Incase Life to be Assured is Minor, please fill details of Minor Life)

i. Height (In cms) Weight (In kgs) Tick

ii. Visible identification marks, if any:_________________________________________________________________________________
Y N
iii. During the last one year, has there been any increase / decrease in your weight over 5 kg?
Y N
iv. During the last 10 years, have you undergone or advised to undergo hospitalization or an operation or any investigation or tests or medical
treatment? Y N

v. During the last 5 years, whether you were under any medical treatment or regular monitoring for more than 14 consecutive days?
Y N
vi. During the last 5 years, have you remained absent from your place of work (Professional or Non Professional) on grounds of health, injury,
mental condition or sickness for 30 consecutive days or more?
Y N
vii. Do you plan or have been advised to undergo any surgery or hospitalization or visit to a doctor or practitioner for any physical, mental or
emotional condition, injury or sickness in near future? Y N
viii. Do you have any physical deformity or congenital/acquired defect?
ix. Have you undergone any test for HIV? Y N
If YES, was HIV present?
x. Have you undergone any test for Hepatitis A/B/C? Y N

If YES, was Hepatitis A/B/C present?

Y N
xi. Have you met with any accident or suffered from any physical impairment /head injuries/ loss of consciousness due to any accident?
xii. Have you ever been tested or treated or have been advised to undergo investigation for a sexually transmitted disease? Y N

xiii. Do you have High Blood Pressure or have you ever suffered or treated or have you been advised to undergo investigation for High Blood
Y N
Pressure?
xiv. Do you have Diabetes or have ever suffered or treated or have you been advised to undergo investigation for Diabetes? Y N

xv. Are you suffering from, or did you suffer or undergo investigation in the past from or have you been advised to undergo investigation or
treatment for: Y N

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 24-Dec-2019 14:52:19 Application No. 9Z023775

a. Cancer/ Leukemia/ Lymphoma Y N h. Bone/ Joint/ Back disease/ Arthritis, etc Y N

b. Kidney disease (Stones, Blood in urine, etc) Y N i. Mental disorders (Depression, Anxiety, etc) Y N

c. Liver disease (Jaundice/ Hepatitis, etc) Y N j. Chronic infections /Circulatory/Blood Disorder Y N

d. Heart disease (Chest pain, Vascular disease, etc) Y N k. Brain/ Nervous System disease/ Stroke Y N

e. Digestive disorder (Ulcer, Gastric bleeding, etc) Y N l. Tumor/ Cysts/ Any other unusual growth/ Lumps Y N

f. Lung/ Respiratory disease (TB, Asthma, Pneumonia, etc) Y N m Eye disease/ Ear disorders Y N

g. Goitre/ Thyroid/ Other Endocrine diseases Y N n. Skin disorders (Psoriasis, etc) Y N

If answers to any of the above Questions is Yes, please give details below:

Nature of Date of Fully Still on Treatment(Y/N). If Yes, Give Details of Name and Address of
Disease/Illness Diagnosis Recovered(Y/N) Treatment Doctor/Hospital

Please submit attending doctor's reports, or hospital reports along with the discharge summary, as applicable
xvi. Do you consume or have ever consumed Narcotic substances or addictive drugs in any form? Y N
Name of Drug: __________________________________ Since When:_____________________________________________________________
xvii. Do you consume or have ever consumed Tobacco in any form (Cigarettes / Beedis / Gutka / Cigar, etc)?
If Yes, Please state No. of Cigarette/Beedis/Cigars_________________________ per day Tobacco/Gutka: _______________________ gms per day Y N
For how many years?___________________________________________________________________________________________________________
xviii. Do you consume or have ever consumed Alcohol in any form or have you suffered from complications due to alcohol consumption?
___________________ml per day. Since When: Y N

14. FOR FEMALE LIVES ONLY:

i. Are you presently pregnant? Date of last delivery: (DD/MM/YYYY) Y N

ii. Have you ever had any abortion or miscarriage or undergone any caesarian operation(s)? Y N
(if so, enclose discharge summary and the gynaecological report)
Number of occasions: _______________________ Date and Cause:_____________________
iii. Have you ever suffered / are you suffering from / undergone any investigation/received any medical advice / consulted a physician Y N

for any gynaecological problem related to uterus, cervix, ovary, breasts,etc or undergone surgical procedure like hysterectomy etc?
If Yes, give details:________________________________________________________________________________________________

Y N
iv. Have you undergone a Family Planning Operation?
v. Husband's Annual Income:
vi. Husband’s Insurance Details:

Name of Insurance Co. Policy No. Yearly Premium ( ) Sum Assured ( )

15. DETAILS OF HOBBIES AND PASTIMES:

Do you take part in any adventurous hobbies/activities that could be dangerous in any way, such as aviation Y N
(other than as a fare paying passenger), mountaineering, diving or any form of racing, etc.?
If yes, give details:__________________________________________________________________________________________________

16. BANK ACCOUNT DETAILS OF PROPOSER/LIFE TO BE ASSURED (MANDATORY)

Please provide accurate details to avoid wrong payments as all future payouts from SBI Life shall be based on the information furnished here.
A/c No. : A/c Type : NRE Savings Current
Bank Name: Bank Branch Name:
Name of the A/c Holder:
MICR Code*: IFSC Code* :
Please submit any one of the below listed document for direct credit of any refunds / payouts if any, to this account.
Copy of Bank Statement Copy of Bank Passbook Cancelled Cheque Annexure 1 (Please sign in black Ink only)
I declare that the information given above is true and correct. I shall not hold SBI Life responsible for non–credit/non - Signature/ Left Hand Thumb Impression
payment of payout or refund, if any,due to any reason including but not limited to incorrect/incomplete information. I hereby
authorise SBI Life to directly credit payout/refund, if any, to the above mentioned account.
Signature/ Left Hand Thumb impression of the Proposer

17. e-INSURANCE A/C DETAILS:

(Please tick) I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository
If opted for the above, please submit requisite annexure with the Proposal Form.
If you already have e-insurance A/C number, please provide the same
e-Insurance A/c No: Repository Name:_____________________________________________________

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 24-Dec-2019 14:52:19 Application No. 9Z023775

18. DECLARATION BY THE PROPOSER/ HUF KARTA/ LIFE TO BE ASSURED:

I hereby declare that the foregoing statements and answers have been given by me after fully understanding the questions and the same are true and complete in every manner and that I have not withheld any
information. Further, I have not provided any false information in reply to any question. I understand and agree that the statements in this proposal constitute warranties. I do hereby agree and declare that
these statements and this declaration shall be the basis of the contract of assurance between me and SBI Life Insurance Co.Ltd. (Company) and that if there is any mis-statement or suppression of material
information or if any untrue statements are contained therein or in case of fraud, the said contract shall be treated as per provision of Section 45 of the Insurance Act, 1938, as amended from time to time. I also
understand and agree to the various charges like Mortality Charges, Policy Administration Charges, Premium Allocation Charges, etc. which will be recovered by the Company by way of cancellation of units/by
deductions from the Premium at the rates approved by IRDAI.I also understand and agree that the company shall additionally levy or recover all the applicable taxes like Service Tax, Surcharges, Cess, etc.
which are necessitated by various enactments of Central and/or State Legislatures from time to time.
I understand and agree that the Net Asset Value per Unit of the Investment Fund may increase or decrease as per the performance of the financial market and other risks.
Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and/or employer from divulging any knowledge or information about me
concerning my health, employment on the ground of secrecy, I, my heirs, executors, administrators and assignees or any other person or persons having interest of any kind whatsoever in the policy contract
issued to me, hereby agrees that such authority, having such knowledge or information, shall at any time be at liberty to divulge any such knowledge or information to the Company.
I hereby authorize the Company to provide my details to banks, financial institutions and third party service providers that the Company may have tie-ups with, for verification of proposal details and for
servicing policies.
I further agree that if after the date of submission of this proposal but before the issue of the premium receipt by the Company (i) if there are any adverse circumstances connected with the general health of
myself, or (ii) if a proposal for assurance of my life made to any other insurance company has been withdrawn or dropped or accepted at an increased premium or on terms other than as proposed by me, or
(iii) if there is any change in my occupation, I shall forthwith intimate the same to SBI Life Insurance Co Ltd. in writing to reconsider the terms of acceptance of this proposal. Any omission on my part to do so
shall render the contract of assurance invalid.
In the event that this proposal is not converted into a policy, I agree that the Company has the right to recover from me, medical expenses (if any) incurred by the Company. I understand and agree that SBI Life
will not be responsible for any delay in premium payment irrespective of any mode for remittance opted.
I understand that the contract will be governed by the provisions of the Indian Insurance Act 1938, and other applicable Statutes and prevailing laws in India and that the risk cover will not commence until a
written acceptance of this proposal is issued by the Company and that the risk cover and other benefits under the policy shall be subject to the terms and conditions contained in the contract of assurance. I
also agree that the amount held in proposal/policy deposit shall not earn any interest.
I further state that the product features and the terms and conditions of the policy have been thoroughly explained to me and that I consent to the same.
"I further request SBI LIFE to send me any information relating to this proposals/resulting policies and I hereby give my consent to receive such information through SMS/Email/Phone/Letter, notwithstanding
any Regulations/Statutory provisions to the contrary. This consent shall hold good even if I register my number with the National Customer Preference Register (NCPR)"
"I hereby declare that the deposit for this proposal has been paid from my own source/income"***
"I hereby understand and agree that no physical document will be issued to me if I have requested for issuing this insurance policy in electronic format to my eInsurance Account.I also agree to receive all
policy related communications through electronic means i.e email,sms,calls,etc"

*** (Strike off in case ‘DECLARATION TO BE GIVEN IF THE PERSON/ORGANISATION PAYING THE PREMIUM IS DIFFERENT FROM THE PROPOSER’ is applicable)
Product Name
For Regular /Limited Premium Policyholders only - Please Note - __________________________________________ is a
Regular Premium/Limited Premium Policy and I am aware that I would need to pay premium for _____ years (Premium Payment Term)

(Please sign in black Ink only) (Please sign in black Ink only)
Signature/ Left Hand Thumb Impression Signature/ Left Hand Thumb Impression
Affix a recent
Signature/Left Thumb impression of the Proposer/Life to be Assured In case Signature/Left Thumb impression of the Proposer
Proposer and Life to be Assured are one and the same person in case different than Life to be Assured self signed
Signature of the Witness : ________________________________________
Photograph

Name and Address of Witness :_____________________________________________________________________________

Date
Place:_________________________________________ : (DD/MM/YYYY)
Please submit KYC documents of witness if other than State Bank Group Staff or our Authorised Representative

19. DECLARATION WHEN THE PROPOSAL FORM IS FILLED BY A PERSON OTHER THAN THE PROPOSER/PROPOSER SIGNS IN A
VERNACULAR LANGUAGE/ PROPOSER IS ILLITERATE:
I hereby declare that I have read out and explained the contents of this proposal form and all other documents incidental to availing the insurance policy from SBI Life I hereby state that the contents of the
Insurance Company Ltd. to the Proposer and that he/she said that he/she has understood the same and that he/she agrees to abide by all the terms and conditions of form and documents have been fully
the same. explained to me and that I have fully
I hereby declare that I have fully explained to the Proposer the answers to the questions that form the basis of the contract of insurance and that if there is any mis understood the significance of the
statement or suppression of material information or if any untrue statement are contained therein or in case if fraud, the said contract shall be treated as per the proposed contract.
provision of section 45 of the insurance Act 1938, as amended from time to time.
I hereby declare that I have explained the contents of this form to the Proposer in___________________ Language, that I have truly and correctly recorded the
answers given by the Proposer and that the Proposer has affixed his/her thumb impression on the proposal form in my presence, after fully understanding the
contents thereof.
Signature of the Person making the Declaration:___________________________________________________________ __________________________
Name and Signature/ Left Hand Thumb impression
of the Proposer

Place:__________________________ Date: (DD/MM/YYYY)

20. DECLARATION TO BE GIVEN IF PERSON / ORGANISATION PAYING THE PREMIUM IS DIFFERENT FROM THE PROPOSER:
Please submit PAN Card/KYC documents/Source of fund* of the person/organisation paying the premium. Date (DD/MM/YYYY)
Pan of Payer:__________________________________________________
Name of Proposer/Life to be assured
I Mr/Mrs/Ms __________________________________________________________husband/wife/father/mother/partner/employer of _____________________________
have given the cheque/DD towards the consideration amount under this policy and have also submitted the source of fund*.
Designation : _______________________________
Address:_______________________________________________________________________
*As applicable under AML Guidelines (Please sign in black Ink only)
A/c No. : Signature/ Left Hand Thumb Impression
Bank Name:_____________________________________________________________________
Signature/ Left Hand Thumb impression of
IFSC Code: the Person/ Organisation Paying the Premium

Section 41 of the Insurance Act, 1938, as amended from time to time

(1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out 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 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.
Extract of Section 45 of the Insurance Act, 1938, as amended from time to time
No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy. A policy of life insurance may be called in question at any time within
three years from the date of the policy, on the ground of fraud or on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the
proposal or other document on the basis of which the policy was issued or revived or rider issued. The insurer shall have to communicate in writing to the insured or the legal representatives or nominees or
assignees of the insured,the grounds and materials on which such decision is based.
No insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement or suppression of a material fact was true to the best of his knowledge and belief or that
there was no deliberate intention to suppress the fact or that such mis-statement or suppression are within the knowledge of the insurer. In case of fraud, the onus of disproving lies upon the beneficiaries, in
case the policyholder is not alive.
In case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on the grounds of fraud, the premiums collected on the policy till that date of repudiation shall be
paid.
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 stated in the proposal.
For complete details of the section and the definition of 'date of policy', please refer Section 45 of the Insurance Act, 1938, as amended from time to time.

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Insurance is the subject matter of solicitation
 24-Dec-2019 14:52:19 Application No. 9Z023775

CONFIDENTIAL REPORT OF SALES REPRESENTATIVE

(To be completed by the Sales Representative after receiving the completed Proposal Form)

Proposal No. Name of the Life to be Assured

Bank Name (For CIF Only) Branch Name Address (For CIF Only) Address Tel. No./ Fax No.

Bank Code (For CIF Only) Branch Code (For CIF Only)

Name of the Sales Representative Sales Representative Code No.

1. Have you personally met the proposer and ascertained his/her identity? Y N

2.Have you fully explained the terms and conditions of the Proposed Insurance plan to the Proposer ? Y N

3. Have you discussed the replies to all questions in the proposal form with the Proposer ? Y N

4. How long has the Proposer been a customer of the branch or known to you ? Years

5. Financial status of the Proposer:

a. Gross Annual Income b. Source of Income

(Salary/ Business/ Other Sources please specify)_____________________________________________________________

c. Are you personally satisfied with the financial standing of the Proposer ? Y N

6. a. What is the general state of health of the Life to be Assured ?_________________________________________________

__________________________________________________________________________________________________
b. Does he/ she have any physical deformity or mental retardation ? Y N

c. Has he/ she undergone hospitalization or any surgery:

Y N
If yes, give full particulars _______________________________________________________________________

7. Are you aware of any other factors not indicated in the proposal form that are likely to add to the risk ? Y N
If yes, give full particulars _______________________________________________________________________

8. Does the Proposer seem to be overweight/ underweight in relation to his/her height ? Y N

9. Identification Mark:__________________________________________________________________________________
Y N
10. Have you verified the authenticity and correctness of name and address mentioned in all the documents and as
stated in the proposal form ?
Y N
11. Whether the Proposer/ Life to be Assured is an NRI/PIO?
Y N
12. Whether the Proposer/ Life to be Assured is a Politically Exposed Person (PEP) or family member/ close relative of any PEP?
If Yes give details:___________________________________________________________________________________________

I do hereby confirm that the above proposal is canvassed by me and that I am satisfied with the identity of the
party. I also declare that the foregoing statements are true and correct to the best of my belief and knowledge.I Date: (DD/MM/YYYY)
hereby confirm that I have followed and completed all the Know Your Customer (KYC) norms as prescribed in
the Anti Money Laundering Policy of SBI Life and in the IRDA Anti Money Laundering Guidelines. I also certify
that I have taken all possible precautions to ensure compliance with the Anti Money Laundering Guidelines and (Please sign in black Ink only)
the Anti Money Laundering Policy of the Company and have verified to the best of my knowledge that the
prospect is not an anonymous, fictitious and / or a benami person. Further, I certify that I have not accepted
any premium or deposit towards procuring insurance in cash. Signature of Sales Representative

Moral Hazard Report Date: (DD/MM/YYYY)

(To be completed,based on the independent assessment, for Proposals with Sum Assured 5 lacs and above.)
• I have discussed the Proposal with the Sales Representative.
• I have scrutinized the Proposal Form, the Sales Representative Report and on the basis of my (Please sign in black Ink only)
independent enquiries, I recommend the Proposal for acceptance.
Name of the UM/BDM/Supervisory Sales Representative:_______________________________
Signature of the UM/BDM/Supervisory
Sales Representative
CHECK LIST
Dear Customer,
Please go through the following check list to ensure that the proposal form is appropriately and completely filled in. This will help in speedy processing of your
proposal for insurance policy. Also ensure that any corrections/erasures/overwriting are countersigned.
Please tick a box against the proof attached/details provided
1. The Age proof attached to proposal form is self attested.
2. The identity proof attached to proposal form is self attested.
3. The address proof attached to proposal form is self attested.
4. A self attested copy of PAN Card / PAN Exemption Form is submitted if annualized premium under the proposed policy is 50000 or above.
5. Complete details of the Nominee are provided in the proposal form.
6. Complete Appointee details are provided in case the nominee is minor.
7. Your Bank Account details along with a cancelled cheque are given in the Bank Account details section of the proposal form.
8. Your telephone or mobile number is given in the proposal form.
9. Your Photograph is affixed at the appropriate place and signed across.
10. Necessary Questionnaires/Addendums are enclosed in case of NRI or HUF proposals.
Also note that you may be required to undergo medical examination, if required, as per the underwriting guidelines of the company.
The details of medical tests to be conducted, if required, shall be communicated to you by SBI Life Branch.
The insurance cover shall commence only after the risk assessment and acceptance by the company and realization of the instrument(s).

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