Date & Time : 6/17/2019 4:15:46

Application Number : 1GPB000700

PM
PROPOSAL FORM - SBI Life- eShield
(UIN: 111N089V03)
SBI LIFE INSURANCE COMPANY LIMITED
Registered & Corporate office: Natraj, M.V. Road & Western Express Highway Junction, Andheri East, Mumbai - 400069.|
CIN:L99999MH2000PLC129113 | IRDA Registration No. 111
Website: www.sbilife.co.in |Email: info@sbilife.co.in| Toll Free 1800 103 4294 (8:30 am to 9:30 pm)
 
 

CALCULATE PREMIUM

Sum Assured : Rs. 7,500,000/- Policy Term : 35 Years

Date of Birth :01-Jan-1984 Gender : ✔ Male Female Transgender

Smoker Status : Smoker ✔ Non Smoker

 

BASIC DETAILS

Title : ✔ Mr. Ms. Mrs. First Name : Saurabh Middle Name :

Last Name : Suman Email ID: saurabh.s@policybazaar.com State / UT : Delhi

Mobile No: +918984519464

✔ I accept SBI Life's Privacy Policy, and by submitting my contact details here, I override my NDNC registration and authorise SBl Life and it’s
authorised representatives to contact me by phone/email/SMS for further assistance and information about this proposal and resulting policy.

QUOTE INFORMATION

Select Plan Plan Description Plan Term Sum Monthly

Plan Option (Years) Assured Premium
(Rs.) excluding
applicable
taxes

✔ Level Cover* During the policy term, on unfortunate death or diagnosis of 35 Years Rs. Rs. 1,007/-
a Terminal Illness**, whichever is earlier, you get Effective 7,500,000/-
Sum Assured and the policy terminates.

Note: You can select any one of the Plan Options

ENHANCE YOUR PLAN

Select Rider Rider Description Rider Term Sum Monthly

Rider (Years) Assured Premium
(Rs.) excluding
applicable
taxes

Note: You have an option to select none, one or both the Riders

Select Premium Payment Frequency : Yearly Half- Yearly Quarterly ✔ Monthly#

#
For monthly mode, upto 3 months premium is to be paid in advance and renewal premium payment is allowed only through Electronic Clearing System
(ECS) or Standing Instruction (where payment is made either by direct debit of Bank Account or Credit Card)

Monthly Premium Rs. 1,007/-

Applicable Taxes Rs. 182/-

Total Monthly Installment Premium Payable Rs. 1,189/-

The taxes shall be applicable as mandated by Government of India from time to time.

Electronically signed by Saurabh suman through One Time Password on 6/17/2019 4:15:46 PM
 * With inbuilt Accelerated Terminal Illness Benefit
** Terminal Illness is defined as the conclusive diagnosis of an illness that is expected to result in death of the Life Assured within 180 days. Such
diagnosis of terminal illness should be by the opinion of two appropriate independent medical practitioners specializing in treatment of such illness.
Medical practitioners should be registered with the Indian Medical Association and approved by the Company. Further, the Company reserves the right
for independent assessment.

e-INSURANCE DETAILS

Note: As per IRDAI e-Commerce Regulations, eInsurance Account is mandatory for online proposals.

✔ I want to receive the Insurance policy and all the information related to the proposed insurance policy through insurance repository?

Do you already have an e-Insurance A/c? * : Yes ✔ No

Request to select any one insurance repository from below options: Karvy Insurance Repository Limited

PERSONAL DETAILS

First Name : Saurabh Middle Name :

Last Name : Suman Marital Status : ✔ Single Married Divorced Widow / Widower

Father’s Name : Fathers Name

Permanent Address :C/o

Line 1 :Hsvsbs Line 2:Nshzbv

Line 3:Jzg zgsv State / UT : Delhi

City :Delhi Pincode :110011

   

Address Proof* :
Driving Licence

Is your permanent address same as your mailing address? ✔ Yes No

C/o

Line 1 :Hsvsbs Line 2:Nshzbv

Line 3:Jzg zgsv

State / UT : Delhi City :Delhi

Pincode :110011  

Address Proof* :
Driving Licence

Resident Status : Resident Indian

PAN Card No*: PPPPP6543P

Nationality : Indian Domicile: Rural ✔ Urban

Mobile No. :+918984519464 Email ID:saurabh.s@policybazaar.com

Tel. No. (Home):NA Tel. No. (Office):NA

You will be asked to submit the relevant proofs (self attested) for Address, Age, Identity and Income after completion of the form and
successful payment

Identity Proof :
Driving Licence

Income Proof :
Assessment Order

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 Age Proof :
Pan Card

Qualifications :
Graduate

   

NOMINEE DETAILS

Nominee is the person nominated by the policyholder to receive the amount under the policy and give a valid discharge to the insurer on settlement of
claim under a life insurance policy.

Title :Mr First Name : nominee

Middle Name : Last Name :name

Mobile No. :9876567656 Email ID:Saurabh@gmail.com

Landline No.:NA Date of Birth :20/06/1990

Gender :Male Relationship with the Life to be Assured :Brother

Is Nominee’s address same as Life Assured’s Address : ✔ Yes No

Nominee Share :100 %  

 
 

OTHER DETAILS

Occupation :
Service

Name & Address of Employer // Workplace : Specify the exact designation : Length of Service (years) :

Name Of School Carmel School Qa 4

Annual Income Rs. :Rs. 12,34,500/-

Did you file your Income Tax Return (ITR) and have Form 16 from previous year? Yes ✔ No

Are you exposed to any special hazard associated with your occupation occupation (e.g. chemical factory, mines, explosives, corrosives,
combative duties, oil exploration, high sea voyage etc.) which may render you susceptible to injuries or illnesses? Yes ✔ No

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, spouses parents or siblings and close associates of PEPs.

If No, 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

Do you have any other individual life insurance policy (from SBI Life or any other life insurer) or have you applied for one? Yes ✔ No

Has any of your proposals been rejected, declined, postponed or accepted with additional premium by any insurance company?
Yes ✔ No
 

FAMILY HISTORY

Status: Alive/ Not Present Age / Age at Present State of If Dead, then Cause of Specify Nature of Illness,
Relation
Alive Death health Death if any

Father Alive 55 Good - -

Mother Alive 56 Good - -

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MEDICAL AND OTHER DETAILS OF THE LIFE TO BE ASSURED:

i. Height 5' (ft) 5'' (In),      Weight 55( Kgs)

ii. Visible identification marks, if any Yes ✔ No

iii.During the last one year, has there been any increase / decrease in your weight over 5 kg? : Yes ✔ No

iv. During the last 10 years, have you undergone or advised to undergo hospitalization or an operation or any investigation or tests or Yes ✔ No
medical treatment? :

v. During the last 5 years, whether you were under any medical treatment or regular monitoring for more than 14 consecutive days? Yes ✔ No

vi. During the last 5 years, have you remained absent from your place of work (Professional or Non Professional) on grounds of Yes ✔ No
health, injury, mental condition or sickness for 30 consecutive days or more?

vii. Do you plan or have been advised to undergo any surgery or hospitalization or visit to a doctor or practitioner for any physical, Yes ✔ No
mental or emotional condition, injury or sickness in near future?

viii. Do you have any physical deformity or congenital/acquired defect? Yes ✔ No

ix. Have you undergone any test for HIV? Yes ✔ No

x. Have you undergone any test for Hepatitis A/B/C? Yes ✔ No

xi. Have you met with any accident or suffered from any physical impairment /head injuries/ loss of consciousness due to any Yes ✔ No
accident?

xii. Have you ever been tested or treated or have been advised to undergo investigation for a sexually transmitted disease? Yes ✔ No

xiii. Do you have High Blood Pressure or have you ever suffered or treated or have you been advised to undergo investigation for Yes ✔ No
High Blood Pressure?

xiv. Do you have Diabetes or have ever suffered or treated or have you been advised to undergo investigation for Diabetes? Yes ✔ No

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:

a. Cancer/ Leukemia/ Lymphoma Yes ✔ No

b. Kidney disease (Stones, Blood in urine, etc) Yes ✔ No

c. Liver disease (Jaundice/ Hepatitis, etc) Yes ✔ No

d. Heart disease (Chest pain, Vascular disease, etc) Yes ✔ No

e. Digestive disorder (Ulcer, Gastric bleeding, etc) Yes ✔ No

f. Lung/ Respiratory disease (TB, Asthma, Pneumonia, etc) Yes ✔ No

g. Goitre/ Thyroid/ Other Endocrine diseases Yes ✔ No

h. Bone/ Joint/ Back disease/ Arthritis, etc Yes ✔ No

i. Mental disorders (Depression, Anxiety, etc) Yes ✔ No

j. Chronic infections /Circulatory/Blood Disorder Yes ✔ No

k. Brain/ Nervous System disease/ Stroke Yes ✔ No

l. Tumor/ Cysts/ Any other unusual growth/ Lumps Yes ✔ No

m. Eye disease/ Ear disorders Yes ✔ No

n. Skin disorders (Psoriasis, etc) Yes ✔ No

xvi. Do you consume or have ever consumed Narcotic substances or addictive drugs in any form? Yes ✔ No

xvii. Do you consume or have ever consumed Tobacco in any form (Cigarettes/BeedisGutka / Cigar, etc)? Yes ✔ No

xviii. Do you consume or have ever consumed Alcohol in any form or have you suffered from complications due to alcohol Yes ✔ No
consumption

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Electronically signed by Saurabh suman through One Time Password on 6/17/2019 4:15:46 PM
 FATCA AND C-KYC DETAILS

Do you have a C- KYC Number? : No C-KYC Number :

Resident Status : Resident Indian Identification Proof : Pan Card

Identification Number : PPPPP6543P Expiry Date :

Spouse Name : NA Country Of Birth : India

Mother's Name : Mothers Name Place of Birth : Ranchi

Are you a tax resident of any country other than India? : No  

 
 

Certification - Under penalty of perjury, I certify that:

● I am aware that Central Board of Direct Taxes (CBDT) has notified Rules 114F to 114H as part of the Income-tax Rules, 1962, (read along with
FATCA/CRS instructions given below) which require Indian financial institutions such as SBI Life to seek additional personal, tax and beneficial owner
information and certain certifications and documentation from all our proposers/ accountholders.
● I understand that SBI Life is relying on information provided in this form for the purpose of determining the status of the accountholder in compliance
with FATCA/CRS. SBI Life is not able to offer any tax advice on FATCA or CRS or its impact on me.
● I acknowledge my responsibility to seek advice from professional tax advisor for any tax questions. I agree to submit a new form within 30 days if any
information or certification on this form changes or becomes incorrect.
● I agree that as may be required by domestic regulators/tax authorities, SBI Life may be required to report, reportable details to CBDT or other
authorities/agencies or may be required to provide information to any institutions such as withholding agents for the purpose of ensuring appropriate
withholding from the policy/(ies) or any proceeds in relation thereto or even close or suspend my policy/(ies), as appropriate.
● I hereby declare that the details furnished in the proposal no. specified above and in this declaration are true and correct to the best of my knowledge
and belief and I undertake to inform SBI Life of any changes there in, immediately. In case any of information furnished in the proposal no. specified
above and in this declaration is found to be false or untrue or misleading or misrepresenting, I am aware that I may be liable.
● I hereby authorize SBI Life to consider details furnished in the proposal no. specified above and in this declaration for the purpose of Central KYC
Registry and to provide my details to CERSAI in the prescribed format. I further hereby consent to receiving information from Central KYC Registry
through SMS/Email or registered mobile number/email address mentioned in the proposal no. specified above.
●I hereby authorize the company to provide my/ours details to banks, financial institutions and third party service providers that the company may have
tie-ups with, for verification of this proposal details and servicing of resulting policy.

FATCA/CRS Instructions

In case Proposer/Accountholder has the following Indicia pertaining to a foreign country and yet declares self to be non-tax resident in the respective
country, Proposer/Accountholder to provide relevant Curing Documents as mentioned below:

FATCA/ CRS Indicia observed (ticked) Documentation required for Cure of FATCA/ CRS indicia

  If Proposer/Accountholder does not agree to be Specified USA person/ reportable person status

1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA nor a
resident for tax purposes of USA;
2. Non-USA passport or any non-USA government issued document evidencing nationality or citizenship
(refer list below); AND
A) United States of America "USA"
A) 3. Any one of the following documents:
place of birth
3a. Certified Copy of Certificate of Loss of Nationality or
3b. Reasonable explanation of why the Proposer/Accountholder does not have such a certificate despite
renouncing USA citizenship; or Reason the Proposer/Accountholder did not obtain USA citizenship at
birth

1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA nor a
Residence/mailing address in a country
B) resident for tax purposes of USA or any other foreign jurisdiction; AND Documentary evidence (refer list
other than India
below)

Telephone number in a country other

1. Self-certification ( as stated above) that the Proposer/Accountholder is neither a citizen of USA nor a
than India
C) resident for tax purposes of USA or any other foreign jurisdiction; AND Documentary evidence (refer list
(and no telephone number in India
below)
provided)

Standing instructions to transfer funds

1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA nor a

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 to an
D) resident for tax purposes of USA or any other foreign jurisdiction; AND Documentary evidence (refer list
account maintained in a country other
below)
than India

List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body**
2. Valid identification issued by an authorized government body**(e.g.Passport,National Identity card, etc.)

**Government/ agency thereof or a municipality of the country or territory inwhich the Proposer/Accountholder claims to be a resident.

13. DETAILS OF PREMIUM REMITTANCE :

Source of Premium Funding Salary  

If the total premium paid by you is Rs 1 lakh and above, please submit documents to show the fund source.

The Premium Paid Option Credit Card 

Name as it appears in Bank Account/ Debit/ credit card Saurabh suman 

Name of Bank/ Credit card issuer  

Bank Account number / Last four Digit of Credit Card Number  

BANK ACCOUNT DETAILS

Account Number :32159499931 Account type : Savings

Bank Name: STATE BANK OF INDIA Bank Branch Name:DISTT. BHADRAK, ORISSA-756100

Name of A/c Holder:Saurabh suman MICR Code:756002100

IFSC:Sbin0000036  

Please submit any one of the below listed documents for direct credit of any refunds / payouts if any, to this account Copy of Bank Statement

I declare that the information given above is true and correct. I shall not hold SBI Life responsible for non-credit/ non-payment of payout or refund, if any,
due to any reason including but not limited to incorrect/incomplete information. I hereby authorize SBI Life to directly credit payout/refund, if any, to the
above mentioned account.

TERMS AND CONDITIONS

I hereby declare that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my knowledge.
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the
insurer and that the policy will come into force only after full payment of the premium chargeable.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of
underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

✔ I agree to the above declaration.

I understand and agree that the statements in this proposal constitute warranties. 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 the provisions of section 45 of the Insurance Act,
1938, as amended from time to time.

I understand that the contract will be governed by the provisions of the Indian Insurance Act 1938, IT Act 2000, and the Indian Contract Act, 1872, as
amended from time to time, and other applicable statutes and prevailing laws in India and that risk cover will not commence until a written acceptance of
this proposal 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 except as prescribed under regulatory
provisions as applicable.

I agree that by submitting this application , I will be bound by all the statements/disclosures of material facts made through the online process in the same
manner and to the same extent, as if I have signed and submitted the written proposal for insurance to the Company.

I also understand and agree that the company shall additionally levy or recover the applicable taxes which are necessitated by various enactments of
Central and/or State Legislatures from time to time.

Electronically signed by Saurabh suman through One Time Password on 6/17/2019 4:15:46 PM
 I further request SBI Life to send me any information or communication relating to this proposal/resulting policy and I hereby give my consent to receive
such information through SMS/Email/Phone /Letter. 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 further declare that the premium is paid from my credit / debit card / internet bank account.

I declare that I am presently in India and I understand that the insurance contract entered into while not in India, will not be valid.

Prohibition of Rebates
Section 41 of Insurance Act 1938, as amended from time to time, states:

a) 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:

b) 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.

Non-Disclosure:
Extract of Section 45, as amended from time to time, states:

a) 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.

b) 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.

c) 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 the date of repudiation shall be paid.

d) 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.

Date:17-Jun-2019
Place:Delhi

 
 

Electronically signed by Saurabh suman through One Time Password on 6/17/2019 4:15:46 PM