Kotak Capital Multiplier Plan UIN: 107N011V01 Name of Life Insured Gender of Life Insured gauri Male Err:508

Date of Quotation Date of Birth of Life Insured Age Tobacco User Plan Details Sum Assured (Rs.) Basic Plan #NAME? Riders: Kotak Accidental Death Benefit Kotak Permanent Disability Benefit Kotak Critical Illness Benefit Kotak Term Benefit Kotak Preferred Term Benefit Kotak Life Guardian Benefit required ? Kotak Accidental Disability Guardian Benefit required ? Policy Fees (Rs.) Total Premium incl of service tax (Rs.) Is Proposer same as the Life Insured Age of Guardian as on last Birthday (in years) Lumpsum Injection Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Date of Maturity Post Vesting Age at the time of Vesting (in years) Accumulation account at the time of vesting (including Supplementary A/c) (Rs.) Cash Withdrawal on vesting (Rs.) Net Vesting value (Rs.) Withdrawal per annum after vesting (Rs.) 23 200000 0 200000 10000 4/1/2026 Amount Date 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Yes 27 #NAME? 10000 15 8.82 4.50 2.29 0.75 234,845 Policy Term in Years 15 Premium Paying Term in Years 15 Yearly (Rs.) #NAME? Half Yearly (Rs.) #NAME? Quarterly (Rs.) #NAME? Monthly (Rs.) #NAME? 24-Jul-11 15-Jul-86 #NAME? No

Do you want to backdate the policy? Yes If yes, kindly specify the backdation date 1-Apr-11

No No 0 #NAME? 15 #NAME? 20 #NAME? 10 #NAME?

Kotak Mahindra Old Mutual Life Insurance Limited Regd. Off:4th Floor, Vinay Bhavya Complex, 159 A ,CST Road, Kalina, Santacruz (East), Mumbai - 400 098, India. Regn. No: 107. Toll Free No.: 1800 209 8800. Website: http://insurance.kotak.com Insurance is the subject matter of the solicitation.

w.e.f. May 11 / Ver 1.8

For Office Use Only (w.e.f. May 11/ Ver 1.8) Proposal No: Policy No:

Kotak Capital Multiplier Plan UIN: 107N011V01 Name of Life Insured Gender of Life Insured Tobaco User Is Backdation required? Date of Backdation gauri Male No #NAME? #NAME? Date of Quotation Date of Birth of Life Insured Age as on Last Birthday (in years) Policy Term in Years Age as per Backdation Date (in years) #NAME? Premium Paying Term in Years Yearly (Rs.) #NAME? 9 Half Yearly (Rs.) #NAME? 5 Quarterly (Rs.) #NAME? 2 24-Jul-11 15-Jul-86 #NAME? 15 #NAME?

Sum Assured (Rs.) Basic Plan Kotak Accidental Death Benefit Kotak Permanent Disability Benefit Kotak Critical Illness Benefit Kotak Term Benefit Kotak Preferred Term Benefit Kotak Life Guardian Benefit Rider Kotak Accidental Disability Guardian Benefit Rider Policy Fee Total Premium Incl of service tax (Rs.) Is Proposer same as the Life Insured Age of Guardian as on last Birthday (in years) Yes No No

Monthly (Rs.) #NAME? 1

234,845 15 10,000 15 - -

#NAME?

15 #NAME?

20 #NAME?

10 #NAME?

Projected Values End of Year Premium (Rs.) Benefits at lower rate2 (Rs.) Fund Value Surrender Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? Benefits at higher rate2 (Rs.) Fund Value Surrender Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? Guaranteed Death C Benefit o m (Rs.) m i #NAME? # s N #NAME? # s N #NAME? # i o #NAME? N # n N #NAME? # ( N #NAME? # R N #NAME? s # N #NAME? . # ) #NAME? N # #NAME? N # #NAME? N # N #NAME? # N #NAME? # #NAME? N # #NAME? N # #NAME? N # N #NAME? # N #NAME? # #NAME? N # #NAME? N # N #NAME? # #NAME? N # #NAME? N # #NAME? N # #NAME? N # #NAME? N # N #NAME? # #NAME? N # #NAME? N # #NAME? N # N

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

#NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME?

w.e.f. May 11 / Ver 1.8

#NAME? Terms & Conditions:

1) Some benefits are guaranteed and some benefits are variable with returns based on the future performance of the company. If the policy offers guaranteed benefits, then these will be clearly marked Guaranteed in the illustration table. If the policy offers variable benefits, then the illustrations will show these based on two different rates of assumed future investment returns. These assumed rates of return are not guaranteed. They are also not the upper and lower limits of what you might get back as the value of your policy is dependent on a number of factors including future investment performance and the future profitability of the Company 2) The benefits at lower rate and higher rate are consistent with the projected return assumption of 6% p.a. and 10% p.a. respectively. This growth rate includes the guaranteed return of 3%. 3) The premium stated in the input sheet is for a healthy individual and would be subject to underwriting. 4) The actual death benefit will be higher than is shown, if the accumulation account is higher than the Basic Sum Assured. 5) The policy can be surrendered only after it has been in force for 3 years and 3 years premiums have been paid in full. The Guaranteed Surrender Value will be 30% of the basic premiums paid after deducting the first years premium and any extra or rider premiums. The surrender value of any subsisting bonus addition already attached to the policy shall be added to this surrender value. The Company may consider paying a Special Surrender Value which will not be less than the Guaranteed Surrender Value. 6) Service Tax, Education Cess and Secondary and Higher Secondary Education Cess on Service Tax, is levied, at the applicable Tax rates in accordance with the prevailing Tax Laws, from time to time. 7) The values shown are for illustrative purposes only. Please see the plan brochure and policy document for the details.

Section 41 of the Insurance Act, 1938 states:(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 provision of this section shall be punishable with fine, which may extend to five hundred rupees.

Declaration by the Proposer I/We confirm that I/we have read and understood the product features, benefits and risk factors, terms and conditions of the proposed plan as set forth in the related product brochure(s) and I/we submit the duly acknowledged sales illustration confirming my understanding of the plan.

Place

Date

Please put Company Seal here.

Signature/Right thumb impression of the Proposer

Name

Signature

Name and Signature of the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker /Relationship Officer

Kotak Mahindra Old Mutual Life Insurance Limited Regd. Off:4th Floor, Vinay Bhavya Complex, 159 A ,CST Road, Kalina, Santacruz (East), Mumbai - 400 098, India. Regn. No: 107. Toll Free No.: 1800 209 8800. Website: http://insurance.kotak.com Insurance is the subject matter of the solicitation.

w.e.f. May 11 / Ver 1.8

For Office Use Only (w.e.f. May 11 / Ver 1.8) Proposal No: Policy No:

Kotak Capital Multiplier Plan - Lumpsum Injection UIN: 107N011V01 Name of Life Insured Gender of Life Insured Tobaco User Is Backdation required? Date of Backdation gauri Male No #NAME? #NAME? Date of Quotation Date of Birth of Life Insured Age as on Last Birthday (in years) 24-Jul-11 15-Jul-86 #NAME?

Policy Term in Years 15 Age as per Backdation Date (in years) #NAME?

Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Benefits at lower rate2 (Rs.) Fund Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME?

Projected Values Benefits at higher rate2 (Rs.) Fund Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? Surrender Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME?

Guaranteed benefit (Rs.) Maturity Benefit #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? Death Benefit #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME?

Surrender Value #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME? #NAME?

w.e.f. May 11 / Ver 1.8

Terms & Conditions:

1) Some benefits are guaranteed and some benefits are variable with returns based on the future performance of the company. If the policy offers guaranteed benefits, then these will be clearly marked Guaranteed in the illustration table. If the policy offers variable benefits, then the illustrations will show these based on two different rates of assumed future investment returns. These assumed rates of return are not guaranteed. They are also not the upper and lower limits of what you might get back as the value of your policy is dependent on a number of factors including future investment performance and the future profitability of the Company 2) The benefits at lower rate and higher rate are consistent with the projected return assumption of 6% p.a. and 10% p.a. respectively. This growth rate includes the guaranteed return of 3%. 3) The premium stated in the input sheet is for a healthy individual and would be subject to underwriting. 4) The actual death benefit will be higher than is shown, if the accumulation account is higher than the Basic Sum Assured. 5) Service Tax, Education Cess and Secondary and Higher Secondary Education Cess on Service Tax, is levied, at the applicable Tax rates in accordance with the prevailing Tax Laws, from time to time. 6) The values shown are for illustrative purposes only. Please see the plan brochure and policy document for the details. Commision for Lump Sum Injection is 2% of each Lump Sum injection Section 41 of the Insurance Act, 1938 states:(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. (2) Any person making default in complying with the provision of this section shall be punishable with fine, which may extend to five hundred rupees. Declaration by the Proposer I/We confirm that I/we have read and understood the product features, benefits and risk factors, terms and conditions of the proposed plan as set forth in the related product brochure(s) and I/we submit the duly acknowledged sales illustration confirming my understanding of the plan.

Place

Date

Signature/Right thumb impression of the proposer Please put Company Seal here.

Name

Signature

Name and Signature of the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker /Relationship Officer

Kotak Mahindra Old Mutual Life Insurance Limited. Regd. Off: 4th Floor, Vinay Bhavya Complex, 159 A ,CST Road, Kalina, Santacruz (East), Mumbai - 400 098, India. Regn. No: 107. Toll Free No.: 1800 209 8800. Website: http://insurance.kotak.com Insurance is the subject matter of the solicitation.

w.e.f. May 11 / Ver 1.8

For Office Use Only (w.e.f. May 11 / Ver 1.8) Proposal No: Policy No:

Kotak Capital Multiplier Plan - Post Vesting UIN: 107N011V01 Name of Life Insured gauri Date of Quotation Age at the time of vesting (in years) Projected Values Benefits at lower rate2 (Rs.) Withdrawals in Accumulation the middle of the Account year 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 199,800 199,700 199,600 199,500 199,400 199,200 199,100 198,900 198,800 198,600 198,400 198,300 198,100 197,900 197,600 24-Jul-11 23

Year

Basic Cover (Rs.)

Benefits at higher rate2 (Rs.) Withdrawals in Accumulation the middle of the Account year 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 205,900 212,300 219,200 226,700 234,800 243,600 253,100 263,400 274,500 286,500 299,500 313,600 328,800 345,300 363,100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485 23,485

w.e.f. May 11 / Ver 1.8

Terms & Conditions:

1) Some benefits are guaranteed and some benefits are variable with returns based on the future performance of the company. If the policy offers guaranteed benefits, then these will be clearly marked Guaranteed in the illustration table. If the policy offers variable benefits, then the illustrations will show these based on two different rates of assumed future investment returns. These assumed rates of return are not guaranteed. They are also not the upper and lower limits of what you might get back as the value of your policy is dependent on a number of factors including future investment performance and the future profitability of the Company 2) The benefits at lower rate and higher rate are consistent with the projected return assumption of 6% p.a. and 10% p.a. respectively. This growth rate includes the guaranteed return of 3%. 3) Basic cover is available only if there is balance in Accumulation A/c and age of life assured is less than or equal to 75. 4) Service Tax, Education Cess and Secondary and Higher Secondary Education Cess on Service Tax, is levied, at the applicable Tax rates in accordance with the prevailing Tax Laws, from time to time. 5) The values shown are for illustrative purposes only. Please see the plan brochure and policy document for the details. 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. Declaration by the Proposer I/We confirm that I/we have read and understood the product features, benefits and risk factors, terms and conditions of the proposed plan as set forth in the related product brochure(s) and I/we submit the duly acknowledged sales illustration confirming my understanding of the plan.

Place

Date

Please put Company Seal here.

Signature/Right thumb impression of the proposer

Name

Signature

Name and Signature of the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker /Relationship Officer

Kotak Mahindra Old Mutual Life Insurance Limited Regd. Off:4th Floor, Vinay Bhavya Complex, 159 A ,CST Road, Kalina, Santacruz (East), Mumbai - 400 098, India. Regn. No: 107. Toll Free No.: 1800 209 8800. Website: http://insurance.kotak.com Insurance is the subject matter of the solicitation.

w.e.f. May 11 / Ver 1.8