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Proposal form no : O10020529

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

State : Pincode : Mobile : Email :

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

Appointee details Name : Mrs. hvjhjfhjgjfhhj gfjhfjhfjgfhj Date of birth : 10/01/1995

Gender : Female

Relationship with nominee : Mother[]

Policy term

Premium paying term

5 Yrs.

Installment premium

Sum assured

Premium frquency

IndiaFirst Anytime 5 Yrs. Plan

6. Fund options Balanced fund


Debt fund

Equity fund

Index Tracker fund


Value fund

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


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


Declaration by the policy holder / Life to be assured

I have seen and understood the benefit illustration with all important details about the plan I intend to purchase. I have also understood the contents of this proposal form along with their importance. In addition, I have also gone through all the sale literature and have fully understood the key features of the plan and the importance of the proposed contract basis the information provided. I confirm that the information provided in this proposal form is full, complete, true and forms the basis of this contract. All material facts including statements in the proposal form, the supplementary documents and information provided to the medical examiner in case of being medically examined which may influence the assessment of risk, have been disclosed. I also understand that failure to make such disclosure will result in the contract being void and the company will be entitled to forfeit all the premiums paid under this policy subject to Sec 45 of the Insurance Act, 1938. I consent to IndiaFirst LifeInsurance Company Limited seeking medical information from any doctor/ hospital in respect of my physical or mental health (present state of health, past health history and nature of work performed) and authorize them to share the required information with IndiaFirst and/ or the claims administrator or medical advisors.Further, I also confirm that I have never participated nor intend to participate in any hazardous sports or activities. I agree that in case of any medical request, the risk in this plan will commence only on the date of acceptance of my proposal by the company.I consent to undergo all medicals as may be required by the Company to assess the risk and grant the insurance. I further agree that if after the date of submission of the proposal but before the issuance of policy (i) there is an adverse change in my occupation, financial condition, health condition which will affect the decision of the Company in underwriting risk or (ii) if a proposal for assurance or an application for revival of the policy on my life or the life to be assured made to any insurer is withdrawn or dropped, deferred, declined or accepted at an increased premium or subject to a lien or on terms other than as proposed, I/we shall forthwith intimate the same to the Company in writing. Failure to do this on my part shall render this assurance invalid and all the monies which shall have been paid in respect thereof shall stand forfeited to the Company. I understand that the cover applied for under this application will commence after approval of my application and receipt of the required premium by the Company. The money paid towards the premium of this plan has not been generated from any criminal activities/ offices listed in the Prevention of Money Laundering Act 2002 or under any other applicable law. I also agree to receive promotional offers/ service alerts/ intimations from IndiaFirst via sms/ email from time to time . Section 41 of Insurance Act, 1938: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. Any person making default in complying with the provisions of the section shall be punishable with fine which may extend to five hundred rupees. Section 45 of Insurance Act, 1938: No policy of 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 insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the Policyholder and that the Policyholder 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 Policyholder was incorrectly stated in the proposal. Free look period:You have a period of 15 days from the date of receipt of the Plan document to review the terms and conditions of the plan and if your disagree to any of those terms or conditions, you have the option to return the plan stating the reasons for your objection. In this case your shall be entitled to a refund of the premium paid, subject only to a deduction of a proportionate risk premium for the period you were covered and the expenses incurred by us on medical examination and stamp duty charges. In respect of a unit linked plan, in addition to the above deductions you shall also be entitled to repurchase the units at the price of the units on the date of cancellation.