CUSTOMER DECLARATION FORM

To

Unique Reference No./Online Proposal Number ________________

Bharti AXA Life Insurance Company Limited

Subject: Submission of Online Proposal for Insurance Policy of Bharti AXA Life Insurance Company Limited (Company)

I/We _________________________________________request you to process the proposal /application with the above mentioned
proposal number submitted online/ digital by me/us on Companys website www.bharti-axalife.com
The name of this Insurance plan is ___________________________________________________________________________
The premium payable is Rs ______________________ on a ____________________frequency for a term of ____________years.
The Sum Assured is Rs _______________________________________ my contact number is __________________________
Email ID is _______________________________________________
I/We hereby confirm that Mr./Ms.________________________has duly filled the details in the proposal form in my/our presence
and in accordance with the information provided by me/us. I/We acknowledge that the information stated in the above mentioned
proposal form is true and correct and I/We have duly checked and verified the same. Further, I/We am/are submitting the requisite
documents (Age/Address/Identity/Income Proof and photograph) as applicable for further processing of the said proposal.
*The Contact details provided by you will be updated in our records. The Email ID will be used for registration to our customer portal
and further communications.I/We ____________________________________________ state, declare, confirm, concur,
understand and agree that

I /we have received, read and fully understood the relevant documentation /information including the product brochure,
KEY feature document, Proposal Form bearing number __________ and Benefit Illustration bearing number
_________________ received on _______________ from ______________@bharti-axalife.com and have understood
and confirm to the product features and Illustration of benefits and the information captured in the Proposal Form.
I/We agree that post my/our meeting with _________________________________bearing license /certificate number
___________ . I /we have submitted the proposal to buy this product on my/our accord after having read and understood
the terms and conditions of the said product on Companys website i.e. www.bharti-axalife.com. I/We have verified the
contents of the Proposal form and understand and agree that by submitting this proposal for Insurance through the
Companys Website, I/we will be bound by such statements/disclosures of material facts in the same manner and to the
same extent as if I/We had signed and submitted a written proposal for insurance after having read and understood the
Illustrations of Benefits.

I/We fully understand the nature of the questions including health related questions and the importance of disclosing all
material information to the Company while answering such questions in the proposal duly filled in online/ digital by me.
I/We declare that answers given by me/us to all questions in the online proposal including the information given to the
Company as to the state of health & habits of the life/lives to be insured are true and complete in every respect.

I/We undertake to notify the Company forthwith, in writing of any changes in my / our health, occupational and financial
state between the date of this proposal and the date of the acceptance of the risk by the Company.

I/We understand that any misstatement, suppression or non-disclosure of material information by me/us or where the
Company is not notified of any change as mentioned above, the Company shall have the right to cancel the Policy or to
repudiate the claim or to declare the policy void in accordance with Section 45 of the Insurance Act and amount, if any,
shall be refunded to the customer based on the policy terms and conditions

I/ We understand and confirm that the Company shall have the sole and absolute discretion to accept, decline or offer
alternate terms on this proposal for life insurance.

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I/We understand that the Company may provide any information available with the Company related to me or this
proposal or the policy to any other insurer, reinsurers, insurance association, medical registrar or statutory authorities,
without any further reference to me/us and I/ We do not have any objection to the same.

I/we hereby declare and confirm that I/we am/are making the premium payment towards this proposal through own bank
account /credit card and I/ we agree to submit a third party declaration in case the premium payment is not made from
own account.

In case of premium payment through Cash, I understand and confirm that I will personally visit the branch office of the
Company for depositing the cash along with this Customer Declaration Form.

In case the proposal is not accepted by the Company, the Company shall communicate their decision alongwith the
refund of proposal deposit within 15 days from the date of submission of last requirement

I / We further state and confirm that whatever is stated, declared, confirmed or agreed above are done/ effected on my/
our own freewill and volition.

Date: ______________Place ___________________

_______________
(Signature of Life Assured)

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______________________
(Signature of Proposer)

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