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Last visited 11/27/2020 11:24:39 PM

Your Online Application Summary

Quote Details Premium Details Document Details

Quote No

444679

Proposal Number

1010458

Policy Chosen

Bharti AXA Life Shining Stars

Policy Number

5021855555

Additional Premium

---

Status

PURCHASED

Last Date Modified

/
 27/11/2020

Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before filling this proposal
form. Insurance is the subject matter of the solicitation.

Insurance is a contract of utmost good faith and the Life to be Insured/Proposer (If different from Life to be Insured) is required to
disclose all material facts to the insurer. All answers to the questions stipulated in this Proposal form are the basis of and are an
inseparable part of the policy of insurance. In case of doubt as to whether a fact is material or not, the fact should be disclosed. In
the event,Life to be Insured/Proposer (If different from Life to be Insured) is unable to fill the form due to inability to read or
understand the language, the help of another person may be used. (Refer to Section 10 - Declaration in case the proposal form is
filled by a person other than the proposer or signed in vernacular). Please answer all questions. If any of the questions are not
applicable please write N.A and please tick a [box] ✓ where appropriate/applicable. Any correction/alteration in this form needs to
be signed by the Life to be Insured/Proposer (If different from Life to be Insured). Should you choose to pay premium by cash you
are advised to do deposit the same at the nearest branch office of the Company.You are advised not to hand over cash to the
sales person. The Company shall not be held responsible for any risk/loss arising out of the customer handing over any money to
the sales person.Please read the sales brochure carefully for details on risk factors, terms and conditions of the product before
filling this proposal form. Insurance is the subject matter of the solicitation.

Bharti AXA Life & You

About Us (https://www.bharti- Privacy Policy (https://www.bharti- Public Disclosures (https://www.bharti-
axalife.com/about- axalife.com//privacy_policy/) axalife.com/public_disclosures/)
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axalife.com/applications/join-us/)
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Keep in Touch
(http://in.linkedin.com/company/bharti-axa-life-insurance)

(https://www.bharti-axalife.com/pdf/IRDA_Clarification.pdf)

Insurance is the subject matter of the solicitation.

Bharti AXA in India
AXA Group (http://www.axa.com/en/)

Bharti Enterprises (http://www.bharti.com/)

Bharti AXA General Insurance (http://www.bharti-axagi.co.in/)

AXA on the web

Insurance Ombudsman (https://www.irdai.gov.in/ADMINCMS/cms/NormalData_Layout.aspx?page=PageNo234&mid=7.2) | Corporate Agents and

Brokers (https://www.bharti-axalife.com/pdf/Date_of_Empanelment.pdf) | Do Not call (https://www.bharti-axalife.com/donotcall/) | Grievance
Redressal (https://www.bharti-axalife.com/policyholder-corner/Grievance-Redressal-Procedure/) | IRDA (http://www.irda.gov.in/Defaulthome.aspx?
page=H1) | Life Insurance Council (http://www.lifeinscouncil.org/) | Citizen Charter (https://www.bharti-axalife.com/pdf/Proposed Citizen
Charter.pdf)

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*For a non-smoking healthy 30-year old male for a 20 year term and death benefit option 1. Actual premium would depend on age, premium payment term
and on underwriting decision. GST and education cess will be charged extra as per the prevailing rates. Premium can be paid only in annual or semi-
annual mode. #Minimum age while applying should be 30 years for cover up to age 75. Services of Dedicated Claims Handler (‘DCH’) is limited to only
helping the claimants in filling up the forms, arranging to collect the documents from the claimant, and providing information about the status of claim on
an ongoing basis on request. While the DCH will facilitate the submission of the claims document for processing the claim, the claim itself will be paid only
/
if admissible under the terms and conditions of the Policy and is subject to receipt of required documents by the Company. The services of DCH cannot be
treated as right of the claimant. Availing or otherwise of this service will not have any impact on the decision of the claim by the Company. Flexible Payout
Option can only be chosen at inception of the policy
Insurance is the subject matter of the solicitation. Life Insurance Coverage available.

Bharti AXA Life Insurance Company Limited (IRDA Regd. No. 130), Regd. Address: Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra
Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra.Service Unit address- Bharti AXA Life Insurance Company
Limited, Spectrum tower, 3rd Floor, Malad link road, Malad (west), Mumbai 400064. Maharashtra. Bharti AXA Life eProtect UIN: 130N052V03, Bharti AXA
Life eAajeevan Sampatti+ UIN 130N072V03, Bharti AXA Life eProtect+ UIN: 130N072V03, Bharti AXA Life eFuture Invest UIN: 130N072V03, Bharti AXA
Life Invest Once UIN: 130N072V03. Advt. No: II-July-2015-1124