PROPOSAL AMENDMENT FORM

Name of Life To Be Assured: _____________________________________________________ Proposal No.: _______________________

I, ____________________________________ the Life to be Assured/ Policy Owner (strike out whichever is not applicable) in the above proposal
would like to make the following changes/corrections to my responses in the Proposal Form dated ___________________ (dd/mm/yyyy):

S. Question No. as Response given in Proposal Change/Correction to be done Any detail/particular

No. per Proposal Form regarding the same
Form

Declaration by the Life To Be Assured/ Policy Owner:

I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information that
may influence the assessment or acceptance of this application. I agree that this form will constitute part of my application for life
assurance with Canara HSBC Oriental Bank Of Commerce Life Insurance Company Ltd and that failure to disclose any mater ial fact known
to me may invalidate the contract.

Date & Place: Signature of Life to be Assured/Policy Owner

Declaration in case Life To Be Assured/Policy Owner signs in Vernacular / Uses Thumb Impression:
I have read out and fully explained the contents of the questionnaire and he/she has understood the same. I have truthfully recorded the
replies given by the Life to be Assured/Policy Owner and that the Life to be Assured/Policy Owner has affixed the signature s/thumb
impression above after fully understanding the contents thereof.

Date & Place: Name and Signature of Declarant

UW/PAF/Ver.1.1 Internal Page 1 of 1