NRI Questionnaire (UWN011)

(To be filled by the Proposer/life to be assured)

Proposal Number :

Name of the Proposer / LA :

Date of birth : Age : Years Male/Female

(Please provide responses to all the questions in the space along side)

Please state your nationality

1

Please state the Country of Current

2
Residence

Date from which you became a

3 permanent resident of country
mentioned above (Point 2)

Please provide Residential address of

4
your current residence located abroad

Please state the duration of your stay

5
abroad

Please state the Purpose of your stay

6
abroad

7 Are you gainfully employed abroad? YES / NO

Full postal address of your employer

8
in the country of residence abroad

Your Employment details including

9 your designation and exact nature of
duties

Are/Have you been entrusted with YES

prominent public functions in a foreign NO
country? Senior Politician
10
Senior Govt/Judicial/Military Official
If YES, please state in which Senior Executive of State owned
capacity? Corporations
Important Political party official

SBI Life Insurance Co Ltd : UWN011 Version 1.4 Dt. 26th March 2022 Page 1 of 5
 NRI Questionnaire (UWN011)
(To be filled by the Proposer/life to be assured)

If engaged in Business, kindly provide

11 the details of the same with
supporting documents

Your monthly income from

12
employment in the foreign country
Point 12 as mentioned above also includes scholarship, assistantship etc for those who
are trainees or students. Please enclose copies of the appointment letter received from
Employer or your Educational Institution.

YES / NO
If you are a student, state the nature
13
and full details of your studies

14 When did you arrive in India?

How long do you intend to stay in

15
India?

16 When are you leaving India?

Please provide Passport details

a.
a. Passport No
b.
17 b. Date of Issue
c.
c. Place of Issue
d.
d. Date of expiry

Do you hold a bank account in India? YES / NO

If YES please provide details. Resident Indian Account

18
Non Resident Indian Account
a. Name of the Bank. a.
b. Name of the Bank Branch b.

By Direct Remittance from the country of

your current residence to India through
Please indicate the manner in which Banking Channels or Postal Channels
you propose to remit premium to SBI
19
Life
By Cheques drawn on your Non Resident
Please tick (√) relevant option
(External) or Non Resident(Ordinary)
Account with a Bank in India

SBI Life Insurance Co Ltd : UWN011 Version 1.4 Dt. 26th March 2022 Page 2 of 5
 NRI Questionnaire (UWN011)
(to be filled by the Proposer/life to be assured)

Extract of the Existing FEMA rules governing settlement of claims

(RBI-A.P.DIR series Circular No.72 dated 17th Jan 2003)

5. Settlement of claims

i. The basic rule for settlement of claims on rupee life insurance policies in favor of
claimants resident outside India is that payments in foreign currency will be permitted
only in proportion in which the amount of premia paid in foreign currency in relation to
the total premia payable.

ii. Non-resident beneficiaries of insurance claims/maturity/surrender value settled in foreign

currency may be permitted to credit the same to NRE/FCNR account, if they so desire.

iii. Resident beneficiaries of insurance claims/maturity/surrender values settled in foreign

currency may be permitted to credit the same to RFC accounts, if they so desire.

iv. Claims / maturity proceeds/surrender value in respect of rupee life insurance policies
issued to non-resident Indians for which premia have been collected in non repatriable
rupees may be paid only in rupees by credit to NRO account of the beneficiary. This
would also apply in cases of death claims being settled in favor of non-resident assignees
/ nominees.
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Declaration to be given by the Proposer/Life to be assured
-------------------------------------------------------------------------------------------------------------------------------
I declare that the answers given above are true and to the best of my knowledge 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 and that
failure to disclose any material fact known to me may invalidate the contract.

Place :

Date : Signature of Proposer/ Life to be assured

-------------------------------------------------------------------------------------------------------------------------------

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 NRI Questionnaire (UWN011)
(to be filled by the Proposer/life to be assured)

NRI Declaration for GST Exemption

I, Mr/Ms _hereby confirm the followings to

SBI Life Insurance Company Limited;

Sl No Details Particulars
1) Foreign communication/permanent address

2) Foreign Bank Account or NRE (Non-residential

bank account number)
3) Amount of Premium
4) Date of Payment
5) Transaction/Reference Number
6) Copy of passport
7) PAN of NRI if available

Above premium has been paid through my NRE/Foreign bank account and I am duly submitting the
following documents along with this declaration:

1. NRE bank statement reflecting debit payment made towards premium amount or letter from
bank confirming account type as NRE account, and premium is paid from same account or
2. Foreign inward remittance certificate for the premium amount

I have provided Electronic Clearing system (ECS) mandate and all the future
policy premium will be debited from above mentioned bank account only.

I hereby confirm that the details and documents submitted by me are true and correct in all aspects.

I am enclosing proof of my above mentioned foreign address and copy of passport.

In case of any change in my residential status from Non-resident to resident in future, I will intimate
Insurance Company within 15 days from such change.

In this regard, I hereby undertake to indemnify the Company for any incorrect/inadvertent claim of
GST exemption made by me on the premium paid along with interest, if any as may be applicable
from time to time as per the GST law.

I will also duly file the declaration to the insurer on or before due date in case of renewal of policy
regarding my NRI residential status and submit the payment confirmation of foreign currency at the
time of payment of premium.

The decision of insurance company will be final for extending the GST exemption and will be binding
on me. In case of non-disclosure or non-availability of documents at the time of payment of premium
(including renewal premium), insurance company will have the exclusive right to charge the GST and
such GST is not refundable to me in future.

Name of Applicant/Policyholder

Signature of Applicant/ Policy holder

Date: Place:
th
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 NRI Questionnaire (UWN011)
(to be filled by the Proposer/life to be assured)

Vernacular Declaration in case the Proposer has signed the

questionnaire in vernacular or Proposer is illiterate
-------------------------------------------------------------------------------------------------------------------------------
I hereby declare that I have read out and explained the contents of this questionnaire to the
Proposer in language and that he/she had understood the
same and the answers were truly and correctly recorded.
I have fully explained that this forms part of the contract and if there has been any non-
disclosure of material fact, the policy may be treated as null and void.

Place :

Date : Signature of person making the Declaration

Name of person making declaration :

Address :

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