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    HDFCPolicyDocument 22

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    Web Techie
    This document is an electronic proposal form for a single life insurance policy with HDFC Life. It collects details about the proposer such as name, date of birth, address, occupation, income, existing policies, and preferred contact details. It also notes that unit linked policies carry investment risk and the proposer is responsible for the investment portfolio chosen. The proposer is asked to provide identity, address and income proofs as well as their PAN number or Form 60 if PAN is not available.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    HDFCPolicyDocument 22

    Uploaded by

    Web Techie
    15 views1 page
    This document is an electronic proposal form for a single life insurance policy with HDFC Life. It collects details about the proposer such as name, date of birth, address, occupation, income, existing policies, and preferred contact details. It also notes that unit linked policies carry investment risk and the proposer is responsible for the investment portfolio chosen. The proposer is asked to provide identity, address and income proofs as well as their PAN number or Form 60 if PAN is not available.

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    HDFCPolicyDocument-22

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    This document is an electronic proposal form for a single life insurance policy with HDFC Life. It collects details about the proposer such as name, date of birth, address, occupation, income, existing policies, and preferred contact details. It also notes that unit linked policies carry investment risk and the proposer is responsible for the investment portfolio chosen. The proposer is asked to provide identity, address and income proofs as well as their PAN number or Form 60 if PAN is not available.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    15 views1 page

    HDFCPolicyDocument 22

    Uploaded by

    Web Techie
    This document is an electronic proposal form for a single life insurance policy with HDFC Life. It collects details about the proposer such as name, date of birth, address, occupation, income, existing policies, and preferred contact details. It also notes that unit linked policies carry investment risk and the proposer is responsible for the investment portfolio chosen. The proposer is asked to provide identity, address and income proofs as well as their PAN number or Form 60 if PAN is not available.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PROPOSAL FORM/ELECTRONIC PROPOSAL

    FORM FOR SINGLE LIFE


    Linked and Non Linked Individual Life Limited Underwriting & Pension Plans

    For Office use only


    Consultant Name & Code: SURYA CHINNASAMY 01097779
    License No: License Expiry Dt: Bancassurance Code:
    Company Lead: Lead Reference No: 1-201488222374 Channel Partner Cust Id:
    IA / CAO Emp No: IA / CAO Name: Branch Code: LW00
    Channel Code: BRCH FOS Code: 00000000 Telecode: 00000000

    ALL UNIT LINKED POLICIES ARE DIFFERENT FROM TRADITIONAL INSURANCE POLICIES AND ARE SUBJECT TO DIFFERENT RISK FACTORS.
    IN UNIT LINKED POLICY THE INVESTMENT RISK IN YOUR CHOSEN INVESTMENT PORTFOLIO IS BORNE BY YOU Photograph of life to be assured*
    to be signed across by the life to
    be assured
    * Not mandatory if life to be
    assured is different from the
    1) The entire form is to be filled in black ink only by the policyholder. Use CAPITAL letters for information required in boxes with a space between Proposer except if Life to be
    assured is minor
    words. 2) Any cancellation / alteration is to be signed by the proposed policyholder or life to be assured as appropriate. 3) All information provided here
    shall be relied on and should be accurate, complete and true in all respects for processing the proposal quickly. In case you have any doubt whether the
    particular information is material or not, please disclose the information. 4) Please attach an extra sheet, wherever additional information is to be given.

    Proposer / Policy Owner Details


    1. Full Name:(Leave a blank Mr. PRAKASH S
    space between First, Middle &
    Last Name)
    2. Maiden Name:(for married woman
    only)

    3. Date of Birth (DD/MM/YYYY): 04/09/1985


    4. Gender(M/F/Tg): Male
    5. Marital Status: Married
    6. Nationality: Indian
    7. Education: BCA
    8. Resident status: Resident Indian
    If you are NRI/PIO/OCI, Please attach
    appropriate Questionnaire.

    Country of Residence:
    If NRI/PIO/OCI

    Country of Workplace:
    If NRI/PIO/OCI

    Permanent Country:
    9. Do you have an existing HDFC If Yes, please provide Policy NO: Annualised Premium:
    Life policy:
    10. Does your spouse have an If Yes, please provide Product
    existing HDFC Life policy: Name:
    11. Are You an employee of HDFC If Yes, please provide Employee Relationship with HDFC Group
    Group or Spouse/child of HDFC ID: Employee(if applicable)
    Group employee:
    12. Correspondence No 84 85 Adithya Grand near, Renukadevi Akkammal, Devasthalam
    Address: Sennemanaikenpalayam Idigarai Coimbatore, Tamil Nadu-641022 India
    13. Permanent Address (If No 84 85 Adithya Grand near, Renukadevi Akkammal, Devasthalam
    different from Sennemanaikenpalayam Idigarai Coimbatore, Tamil Nadu-641022 India
    correspondence address)/
    Overseas residential
    address for NRI / PIO / OCI :
    14. Mobile: 919600718774
    Telephone No(R):
    Telephone No(O):
    E - mail ID: [email protected]
    Email ID if provided, will be
    considered as preferred mode of
    communication

    15. Preferred language of English


    communication:
    16. Present Occupation: Salaried
    Gross Yearly Income 11,00,000
    (INR):
    Workplace Name and KOVAI SYSTEM INDIA PVT LTD , Coimbatore , Tamilnadu ,
    Address:
    ^ if Retired, please provide name of
    last organisation

    Industry Type (cement, Service


    baking, etc.):
    Exact Nature of work
    (clerical, mechanical,
    supervisory job, etc.):
    Nature of Occupation Lead System Designer
    (architect, etc.):
    17. Income Proof (proposer): Identity Proof (Proposer):
    Address Proof Age Proof (Life Assured):
    (Proposer):
    PAN* (Proposer): BHBPP8427R
    18. PAN Photocopy BHBPP8427R
    enclosed :(*Submit Form 60 if PAN
    is not available)

    19. Do you want policy in No E insurance account number:


    Demat form?If a policy is requested
    in demat form, it will not be given in
    physical form and vise versa.
    22 of 27
    20. Is the Policy holder same Yes
    as Life Assured

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