Financial Need Assessment Form

Version 2.0

Proposal Form No : 9101930505

sushma sushma
Name:_____________________________________________________________________________________________________________________
Current Age: _________________________
36 Planned Retirement Age: _______________________
60 No. of years to Retire:
_________________________
24 Total Annual Income Net of Taxes (`): _______________________
500000 Annual Expenses (`): __f_______________
100000
Annual Savings (`):_________________
400000
Help us know you better, please share your family details
Family Member Name Age Occupation Annual Income (Optional)
Spouse

Child 1
Child 2
Child 3
Father
Mother

A: Total Life Cover Need for Income Replacement 12000000

(Total annual income net of taxes x time to retirement, in years)

B: Add Current liabilities (`)

(Total mortgage amounts, personal loans, education loans etc.)

C: Total Sum Assured of existing life insurance policies

(Include group insurance, personal insurance, mortgage insurance)

Risk Cover Need/Assets E: Total

to be created (` @ Existing GAP (`) Time to Goal
Future Goals Priority
Current Market value) Assets (`)^ F = (D-E) (No. of Years)
(D) (E)

Protection (Securing Lifestyle)

Total risk cover need (A+B)-(C)

Education & Marriage

Child's education – home or abroad
Child's marriage

Retirement Planning/ Supplement Income

Retirement need for self, spouse & dependents

Managing & Growing Wealth

Purchasing an asset 200000 2000000 0 Upto 10 years 1
Estate planning etc.
Based on the Priority & Affordability, agreed Risk-Cover
(Sum assured in `)

Are you worried about any major illness and it's huge financial implications. Yes No ✔

Do you have a family history of any major critical illness and want to be financially ready for the eventuality Yes No ✔

Do you belong to the segment of the society which is vulnerable to lifestyle diseases and want to safeguard yourself from the future expenses Yes No ✔

Do you want to be covered over and above your medicalim policy so that you are financially protected in case of critical illness Yes No ✔

Any other information you wish to furnish pertaining to this need analysis : ________________________________________________________________
^Total Existing Assets: Mutual Funds, Fixed Deposits, Public Provident Fund (PPF), House, Farm Land, Business Assets, Gold – exclude own house wherein you & your family live in.
 Select (ü) your preference to see what type of insurance may be right for you:

1. In traditional plans, premium invested is generally protected and investment risk is with the insurance company.
I do not like the idea of risking my capital. My objective is to at least earn a guaranteed payout on my investment and
shelter these amounts from market fluctuations along with life cover.
✔
Yes to
Traditional Plans

2. In unit linked products ( ULIPs), returns are based on market movement and the investment risk is with the policyholder. Yes to
I am comfortable that the value of my investments will fluctuate and there may be loss/gain in the value of my invested Unit Linked Life
fund(s), in return for a potentially better chance of earning higher returns in the long term. Insurance Plans

Select (ü) one of the following statements which best reflects the financial risk that you are willing to take,
when investing in Unit Linked Insurance Plan (ULIPs)?

A. Security of money invested in funds is important to me. I am only prepared to accept minimal risk of investment loss; I understand Low Risk
(BLUE)
that over a long term this may lead to potentially lower returns.
B. While security of money invested in funds is important, I am prepared to accept some fluctuations in the value of my funds and a Medium Risk
(YELLOW)
limited chance of investment loss.
C. I aim at maximizing returns over the long term. I can tolerate higher fluctuations on my invested funds (similar to movements in share High Risk
prices) and a chance of loss in value of my investments. Hence, I would like to pursue potential for higher returns over the long term. (BROWN)

Declaration (Select the Appropriate Option):

I Based on my future goals, affordability and risk profile, I would like to proceed further with the recommendation of Licensed Branch
Staff. The product recommended is ___________________________________________________________________
Canara HSBC Life Insurance Guaranteed Savings Plan (Name With
of the Product) with an affordable annual/semi annual/quarterly/monthly premium of ` ______________________ 25000 and ✔
Recommendation
Premium Payment Term of __________________ years with the Fund Option of _________________
5 Not Applicable (in case of Unit Linked
Insurance Plan).
II Based on my future goals, affordability and risk profile, I would like to proceed further against the recommendation of Licensed
Branch Staff. The product selected is _________________________________________________ (Name of the Product) with Against
Recommendation
an affordable annual/semi annual/quarterly/monthly premium of `__________________ and Premium Payment Term of
___________________ years with the Fund Option of ____________________ (in case of Unit Linked Insurance Plan).
III Based on my requirement of the health policy I would like to proceed further with the recommendations of the Licensed Branch staff.
The product recommended is _______________________________________________________ (Name of the product) with With
Recommendation
an affordable monthly/quarterly/semi annual/annual premium of _______________ and premium payment term of ________
years with a policy term of ________________ years.

I confirm that the information provided is true and correct to the best of my knowledge.
Electronically validated through OTP on
Customer’s Name: _______________________________
sushma sushma 16/11/2022

Date 16/11/2022
Customer’s Signature/Thumb Impression

I/We confirm having explained the complete product details of all the available products and the customer/Proposer has selected the above product voluntarily
as per the above declaration and there is no compulsion/forced selling in soliciting the Proposal.
LBS Name: _________________________________
Saurabh Tiwari

Branch Name: _______________________________

Delhi Vasanthkunj
Licensed Branch Staff Signature
Date 16/11/2022

Declaration for customer signing in vernacular Language/Thumb Impression:

I _______________________________________________________ Son/Daughter of ____________________________________________________,

adult and residing at ___________________________________________________________________do hereby declare on solemn affirmation as under:
I have read out and fully explained the contents of Financial Need Assessment Form in ___________________________________________________
language incidental to availing the insurance policy from Canara HSBC Life Insurance Company Limited to Mr./Mrs./Ms.
__________________________________________________________________ and he/she has understood the significance of the proposed solution. I
have truthfully and correctly recorded the replies given by the Proposer/Life to be Assured and that the Proposer/Life to be Assured has affixed the
signature above after fully understanding the contents thereof. Solemnly affirmed at _____________________________ on _________________________.

Signature of Declarant

Canara HSBC Life Insurance Company Limited (IRDAI Regn. No 136) Registered Office: Unit No.
208, 2nd Floor, Kanchenjunga Building, 18 Barakhamba Road, New Delhi-110001 Corporate Identity
No. - U66010DL2007PLC248825

Toll-free at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 9779030003

E-mail us at customerservice@canarahsbclife.in Visit us at our website www.canarahsbclife.com
 PROPOSAL FORM
Proposal No: 9101930505
Unique Reference Number: CPF/V6.10/052022
“IN UNIT LINKED POLICIES, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.”
For Office use only
Bank/Channel Name ________________________________________________________________
CANARA BANK

Bank/Channel Code ______________________

CAN ________________________
Client’s Branch/DSP Code 3159
Bank Account No. _______________________________________________________________
125002789132
Please affix recent
Customer Client No. _______________________________________________________________ Passport size
photograph of Proposer
BR Name ___________________________________________________________________
Saurabh Tiwari and Sign across
the photograph
BR Code _______________________________ ISM Code
106838
________________________________
NA
DO NOT STAPLE
Customer Referred by Employee (Name) __________________________________________________ THE PHOTOGRAPH

Referred by Employee (No.) _________________________________________________________

Type of Insurance Employer Employee HUF ✔ Individual MWP Partnership Firm Salary Deduction Key man
Relationship with Bank SB Account ✔ CA Account Deposit Advance-Borrower Credit Card
Staff YES ✔ NO Corporate Customer YES NO POS YES NO POSP-LI: PAN No:____________________
Important Guidelines:
1. Insurance is a contract of utmost good faith, requiring the Proposer and the Life to be Insured and the insurer to disclose all material facts. If there is any
doubt as to whether any fact is material, it should be disclosed. Failure to do so may invalidate the contract based on this form.
2. ALL INFORMATION IN THE PROPOSAL TO BE FILLED IN CAPITAL LETTERS USING BLACK BALL POINT PEN

Personal Details of Life to be Insured

1. Life to be Insured name Title Mr. Mrs. ✔ Miss Ms. Other (specify) __________________________________________
First Name ___________________________________________________________________________
sushma

Middle Name ___________________________________________________________________________

Last Name ___________________________________________________________________________
sushma

2. Is Life to be Insured our existing policyholder/applicant, kindly tick as applicable: Yes ✔ No If Yes, Policy/Application No _____________________
3. Father’s Name Title ✔ Mr. Other (specify) ______________________________________________________________
First Name ___________________________________________________________________________
RAJENDER

Middle Name ___________________________________________________________________________

Last Name ___________________________________________________________________________
SINGH

4 a) Date of Birth ___________________________________

01/08/1986
Delhi
b) Country of Birth India
______________________ c) City of Birth ______________________ d) Gender Male ✔ Female Transgender

d) Age Proof Driving License School/College Certificate Municipal Birth Certificate Passport

✔ PAN Card Other (specify) ___________

e) Marital Status ✔ Unmarried Married Widow(er) Divorcee
5. Is Life to be Insured ✔ Resident Indian NRI (Non Resident Indian) PIO (Person of Indian Origin)
Foreign National Other (specify) __________
(Please fill NRI/PIO/Foreign National Questionnaire if applicable. In case of NRI/PIO/Foreign National, all correspondence and communication shall
be sent to the address provided for such purpose in the NRI/PIO/Foreign National Questionnaire)
6. a) Country of current Residence _______________________
India b) Citizenship India
__________________ (Please specify in case of multiple citizenship)

c) Nationality _______________________
India (Please specify in case of multiple nationalities) Pin Code is mandatory.

7. Communication Address Current Residential Address ✔ Permanent Residential Address Office Address
8. Current Residential Address NEHRU BHAWAN P.NO 5, INST AREA PHASE 2
______________________________________________________________________________
_________________________________________ Area/Taluka/Tehsil_________________________________
VASANT KUNJ

City/District ___________________________________________________
DELHI State ______________________________
Delhi

Country _____________________________________________________________
India Pin Code 110070
_____________
_
9. Permanent Residential Address ________________________________________________________________________________
NEHRU BHAWAN P.NO 5, INST AREA PHASE 2

VASANT KUNJ
_________________________________ ____________Area/Taluka/Tehsil _____________________________________
City/District ______________________________________________________
DELHI State ______________________________
Delhi

Country __________________________________________________________________
India Pin Code ______________
110070

10. a) Name of Organisation /Business/Educational Institution _________________________________________________________________________

MINI MART

b) Nature of industry of the Employer/Organization_______________________________________________________________________________

Others

Common Proposal Form Version 6.10 Page 1 of 10

 PROPOSAL FORM
Proposal No: 9101930505
11. Office Address ________________________________________________________________________
NA

__________________________________________________ Area/Taluka/Tehsil_____________________________________________
NA

City/District NA
_________________________________________________________ State ___________________________________________
NA

Country ________________________________________________________________________
India Pin Code ____________________________
NA

12. Education/ MBA LLB Doctor Engineer ICWA/CFA/CS/CA ✔ Graduate

Professional Qualification Std XII Pass Std X Pass Other (Specify) ______________________________________________
13. Occupation Salaried Housewife Student ✔ Business Owner/ Self Employed Non-working
Retired
14. Exact nature of occupation/duties ____________________________________________________________________________________________
Business of Retail & Wholesale - Grocery
(Specify if you are in money services /lottery / casino/gambling/horse jockey/NGO/Trust/Charity/Real Estate/Jewelry/Scrap Dealer/Diamond dealer)

15. Are there any risks associated with the Life to be Insured’s occupation? e.g. Working with Boiler, Explosives, Chemicals, etc. Yes ✔ No
If Yes, Please fill up the appropriate questionnaire. ________________________________________________________________________
16. Annual Income (Rs.) ________________________________________________________________________
500000

17. Does Life to be Insured take part in hobbies that are risky in any way? e.g. Aviation, Diving, Mountaineering etc. Yes ✔ No
(If Yes, Please submit appropriate questionnaire.)
18. Is the Life to be Insured a Politically Exposed Person (PEP)? Yes ✔ No
(PEPs are individuals who are or have been associated with a political party/politician or holding any senior role in any ministry/government/state owned enterprises/judicial body/military/police in India or
abroad or those individuals who have any close family members or associates in the said capacity) If yes, please provide details

_________________________________________________________________________________________________
NA

_____NUMBER__________________
19.Contact details: Mobile: ISD Code NA 8586893839 Alternate Mobile: ISD Code ______NUMBER____________
NA 00000000000

Telephone/Mobile Number
wherever available
Residence Number Ph: STD Code.NA
_____NUMBER___________
NA __
____ _______________________________
Email sushmas92@yahoo.com

Personal Health Details of Life to be Insured

1. Height 5 ft 2 inches OR 157 cms Weight 60 kgs

2. Has your weight altered by more than 5 Kgs. in the last 1 year for reasons other than exercise? No
_____________________________________________
3. Please give the following details
If yes,
Substance Consumed Yes/No consumed as Consumption Quantity For No. of years

Tobacco N Y/N NA NA Nos. per day NA

Alcohol N Y/N NA NA (ml/week) NA

Any Narcotics N Y/N NA NA

4.1 Please provide medical details as asked in the following questions: (To be filled for Life to be Insured for Life Insurance Product, Major Critical Illness
& Heart Cover under Health Product)

Medical Details of Life to be Insured (Applicable for Life Insurance Product, Major Critical Illness & Heart Cover under Health Product)

Have you ever :

Yes No ✔
1. Been hospitalized for general checkup, observation, treatment or surgery?
2. Been prescribed treatment or medication for a current injury or ailment? Yes No ✔
a.
3. Availed more than 5 days continuous leaves on medical grounds in the last 2 years or consulted a doctor/visited a Yes No ✔
clinic in the past 6 months ? If yes, please provide details
4. Undergone/ Advised X-ray/CT-Scan/MRI/Ultrasound/ECG/Blood Test/any other tests/investigations Yes No ✔

5. Undergone/Advised test/tested positive for Hepatitis, HIV/AIDS or any other sexually transmitted disease? Yes No ✔

Have you ever suffered or are you suffering from any of the following?
1. Any ailments relating to heart like high/low blood pressure, chest pain, palpitation, rheumatic fever heart attack, Yes No ✔
shortness of breath ,any other heart disorder or stroke etc.
2. Any ailments related to the brain & nervous system like epilepsy, stroke, depression, mental disorders etc. Yes No ✔

3. Tumour, cancer, cyst, abnormal growth or any other malignancy Yes No ✔

4. Disorders of eye, ear, nose or throat including defective sight, speech or hearing and discharge from ears Yes No ✔
b. 5. Asthma, bronchitis, tuberculosis, difficulty in breathing, persistent cough or any other lung disorder Yes No ✔
6. Ailment related to liver, gall bladder, stomach and digestive system like ulcers, stones, colitis, stomach pain,
jaundice, hepatitis B or C etc. Yes No ✔

7. Any gland related disorder like diabetes/high blood sugar, sugar in urine, thyroid etc. Yes No ✔
8. Any kidney system or urinary bladder disorder like stones, nephritis, prostate disorder, reproductive organs etc. Yes No ✔
9. Musculoskeletal & joint disorder like gout, rheumatic arthritis, back disorder, skin disorder etc. Yes No ✔
10. Anaemia, disorders of blood (e.g. Haemophilia, Thalassemia) or any other illness not mentioned in (1 to 10) Yes No ✔
11. Any physical disability/deformity, congenital disorder, paralysis or multiple sclerosis Yes No ✔

Common Proposal Form Version 6.10 Page 2 of 10

 PROPOSAL FORM
Proposal No: 9101930505

Please provide details if answer of any of the above question is answered as “Yes”
Question Number Details

The Company reserves the right to ask for medical tests or/ seek further information based on above answers.
Please submit Previous Medical Reports (if any) and relevant questionnaire (s)

4.2 Please provide medical details as asked in the following questions: (To be filled for Life to be Insured if Health Product is Opted)

Additional Medical Details of Life to be Insured (Applicable only for Major Critical Illness & Heart Cover)

a. Have you consulted any doctor for surgical operations or have been hospitalized for any disorder or been advised to
undergo/have undergone any medical investigations/treatment for medical conditions other than for minor cough, Yes NA No NA
cold or flu during the last 5 years?
b. Are you currently taking or in the past have taken any treatment or medications for any condition for a continuous Yes NA No NA
period of more than 14 days? (except for minor cough, cold, flu, appendix, typhoid )
c. Have you ever availed insurance cover under 'Heart/ Cardiac product/Critical illness cover' through any insurance Yes NA No NA
company in India? If yes, please share details Name of company , Sum Assured
d. Have you ever suffered from or have been advised that you have any of the following conditions ?
Yes NA No NA
1. High Cholesterol/lipids:
2. Excessive fatigue/syncope/dizziness: Yes NA No NA

3. Persistent fever or headache Yes NA No NA

e. Have you ever had, or been told that you have or are currently undergoing investigation for Abnormal findings in ECG, Yes NA No NA
TMT, CXray, Echo, Angiography or any other cardiac investigations ?
f. Have any of your immediate family members been diagnosed with prior to age of 60 years from Heart disease, high blood Yes NA No NA
pressure, stroke, Diabetes, kidney disease, cancer or any other disease/ailment?

Please provide details if answer of any of the above question is answered as “Yes”

Question Number Details

The Company reserves the right to ask for medical tests or/ seek further information based on above answers.
Please submit Previous Medical Reports (if any) and relevant questionnaire (s)

4.3. Please provide medical details as asked in the following questions: (To be filled for Life to be Insured if Health Product is Opted)

Medical Details of Life to be Insured (Applicable when Cancer Cover is opted)

a. Have you availed insurance cover under “Stand-alone Cancer product” through CANARA HSBC LIFE INSURANCE or
Yes NA No NA
through any other Insurer in the Indian insurance market?
If answer “Yes” please mention the Sum Assured availed , year of commencement & name of the Insurance Company below
b. Have you suffered from or been advised investigation/investigated or been treated for any form of Cancer, sarcoma,
tumor, or pre-cancerous conditions (few example but not exhaustive are Barrett's esophagus, atrophic gastritis, Yes NA No NA
cervical dysplasia, leukoplakia)
c. Are you suffering from or ever suffered from, Hepatitis B, Hepatitis C, Liver disease due to alcohol, Barrett's Esophagus,
Yes NA No NA
Crohn's Disease, Peptic Ulcer, Ulcerative Colitis?
d. Have you suffered from or been investigated for any of the following
1. Recurrent cough, hoarseness of voice, or difficulty in swallowing for a continuous period of 15 days?
2. Any persistent loss of blood or unusual discharge from any part of the body? Yes NA No NA
3. Any ulceration, growth, nodule, cyst or lump in any part of the body?
e. Have you had abnormal findings in any of the listed investigations in the last 6 months (if applicable)-
[] Ultrasound [] Endoscopy/Colonoscopy [] CT Scan / MRI [] Biopsy [] PAP Smear [] Mammography Yes NA No NA
[] Blood test for cancer diagnosis (Tumor Marker)
f. Have any of your parents (below age 60 years), sisters or brothers suffered from any form of cancer Yes NA No NA
g. Are you suffering from or ever suffered from HIV/AIDs, Chronic Glomerulonephritis, Chronic Kidney Disease, Yes NA No NA
Polycystic Kidney Disease, Anemia?
h. Are you suffering from or ever suffered from Fatty liver, Gastritis, Gastro-Esophageal Reflux? Yes NA No NA

Common Proposal Form Version 6.10 Page 3 of 10

 PROPOSAL FORM
Proposal No: 9101930505

Please provide details if answer of any of the above question is answered as “Yes”

Question Number Details

The Company reserves the right to ask for medical tests or/ seek further information based on above answers.
Please submit Previous Medical Reports (if any) and relevant questionnaire (s)

To be filled if the Life to be Insured is a Female (For Females only)

1. Maiden Name of the Life to be Insured __________________________________________________________________________________________
NA

2. Is the Life to be Insured pregnant at present? Yes ✔ No If yes, duration in weeks _______________________________
NA

3. Did the Life to be Insured ever suffer from or at present suffering from any gynecological related problems? Yes ✔ No
4. a. Husband’s Name ________________________________________________________________________________________________________
NA

b. Annual Income _________________________________________________________________________________________________________

NA

Previous Insurance details of Life to be Insured

1. Life Insurance/Health Insurance already In Force/Lapsed/Revival/Applied for (including policies surrendered during the last 3 years)
(Please attach additional sheet if necessary with details as mentioned below)

Issuing Life Years of Sum Annual Riders Acceptance Terms

Insurance Company Issue Assured (Rs.) Premium (Rs.) if any (Std./With Med Extra/With Non Med Extra)

Not Applicable

Not Applicable

Not Applicable

Not Applicable

2. Has a proposal on Life to be Insured’s life ever been withdrawn/postponed/declined/dropped or accepted with modified terms /extra premium or has Life
to be Insured ever made any claim under a policy of Life/Health Insurance? Yes ✔ No
If yes, please give details_____________________________________________________________________________
NA

Family Health Details of Life to be Insured

Please furnish details of family members of the Life to be Insured. Also in case of any family members suffering or having suffered or died of heart disease,
stroke, high blood pressure, diabetes, any form of eye disease, kidney disease, paralysis or any hereditary/familial disorders, any communicable disease,
or any disease not mentioned above, mention the same in the following table. If the Life to be Insured is not aware, please leave it blank, the Company
could ask for clarifications later. Please attach additional sheet if necessary with details as mentioned below.

If Alive If Deceased

Mention the name of

Family Member Current Age Cause of Death Age at Death
disease/illness (if any)

Father 57 Good Health Not Applicable Not Applicable

Mother 56 Good Health Not Applicable Not Applicable

Spouse Not Applicable Not Applicable Not Applicable Not Applicable

Brother(s) Not Applicable Not Applicable Not Applicable Not Applicable

Sister(s) Not Applicable Not Applicable Not Applicable Not Applicable

Nominee Details

Note: Nominee/Beneficiary details to be provided, only where Life to be Insured is proposing on self (In case of Multiple Nominees/ Beneficiaries, please
fill up Multiple Nomination Form)
1. Nominee / Beneficiary Name Title ✔ Mr. Mrs. Miss Ms. Other (Specify) ____________________
NA

First Name _______________________________________________________________________________________________________

RAJENDER

Middle Name _______________________________________________________________________________________________________

Last Name ______________________________________________________________________________________________________
SINGH

2. a) Date of Birth ________________________

10/08/1968 b) Gender ✔ Male Female Transgender

3. Nominee Relationship with Spouse Son Daughter ✔ Father Mother Other (Specify) ______________
Life to be insured
Pin Code is mandatory
4. Address of Nominee/Beneficiary _______________________________________________________________________________________________________
NEHRU BHAWAN P.NO 5, INST AREA PHASE 2

VASANT KUNJ
________________________________________________Area/Taluka/Tehsil________________________________________

Common Proposal Form Version 6.10 Page 4 of 10

 PROPOSAL FORM
Proposal No: 9101930505

Delhi
__________________________________________________________
City/District DELHI
______________________________________ State
Country _______________________________________________________________________________
India ___________________
Pin Code 110070
_______________________ Alternate Mobile with ISD Code ______________________
NA
5. Contact details: Mobile with ISD Code 0000000000

Telephone/Mobile Number Residence Ph. _______________________________

NA Email _______________________________
NA
wherever available

Appointee or Guardian Details (Other than the Life to be Insured), if the Nominee/Beneficiary is a minor (below 18 yrs)

1. Name of Appointee/Guardian Title NA Mr. NA Mrs. NA Miss NA Ms. NA Other (Specify) ____________________
NA

First Name _______________________________________________________________________________________________________

NA

Middle Name _______________________________________________________________________________________________________

NA

Last Name _______________________________________________________________________________________________________

NA

2. a) Date of Birth ________________________

NA b) Gender NA Male NA Female NA Transgender

3. Relationship with the Nominee/Beneficiary NA Spouse NA Son NA Daughter NA Father NA Mother NA Other (Specify) ______________
NA

4. Address of Appointee/Guardian _______________________________________________________________________________________________________

NA
NA
_____________________________________________ Area/Taluka/Tehsil ____________________________________________
NA

State ___________________________________________________________
NA
City/District ________________________________________
NA

Pin Code _____________________

NA
Country ______________________________________________________________________________
NA

5. Contact details: Mobile with ISD Code ________________________ Alternate Mobile with ISD Code _______________________
NA NA

______________________________ Email _______________________________

Telephone/Mobile Number
wherever available Residence Ph. NA NA

Personal details of Proposer/Life to be Insured

Please fill as per instructions

(PLEASE FILL DETAILS OF PROPOSER FOR Q.1 TO Q.22 WHERE LIFE TO BE INSURED AND THE PROPOSER ARE
DIFFERENT)(PLEASE SKIP Q.1 to Q.12 IF THE LIFE TO BE INSURED AND THE PROPOSER ARE SAME)
1. Proposer Name Title NA Mr. NA Mrs. NA Miss NA Ms. NA Other (Specify) ________________________________
NA

First Name
___________________________________________________________________________________________________
NA
Middle Name _________________________________________________________________________________________________
NA
Last Name _________________________________________________________________________________________________
NA

2. a) Date of Birth _______________________

NA b) Gender NA
Male NA Female NA Transgender
3. Father’s Name Title Mr. Others (Specify) _____________________________________________________
NA NA NA ________
First Name __________________________________________________________________________________________________
NA

Middle Name NA
________________________________________________________________________________________________
Last Name ________________________________________________________________________________________________
NA

4. Is Proposer NA Resident Indian NA NRI (Non Resident Indian) NA PIO (Person of Indian Origin)

NA Foreign National NA
Company/ Partnership Firm/ HUF Other (Specify) ________________________________
NA

(Please fill NRI/PIO/Foreign National Questionnaire if applicable. In case of NRI/PIO/Foreign National, all correspondence and communication shall be
sent to the address provided for such purpose in the NRI/PIO/Foreign National Questionnaire)
5. Marital Status NA
Unmarried NA
Married NA
Widow(er) NA
Divorcee
NA
6. a) Country of Residence NA
___________________________________________________ b) Country of birth _______________________________________
c) City of Birth ______________________________________________
NA d) Citizenship NA
_____________________ (Please specify in case of multiple citizenship)

e) Nationality ____________________________
NA (Please specify in case of nationalities) __________________________________
f) Annual Income (Rs.) NA
7. a) Occupation Salaried Retired Housewife Student Business Owner/Self Employed
NA NA NA NA NA

b) Exact nature of occupation/duties _________________________________________________________________________________________

Not Applicable
(Specify if you are in money services/lottery/casino/gambling/horse jockey /NGO /Trust /Charity/Real Estate/Jewelry/Scrap Dealer/Diamond dealer)
Not Applicable
c) Organization/Employer Name _____________________________________
Not Applicable d) Nature of industry of the Employer/Organization___________________
e) Office Address – Country _________________________________________
Not Applicable f) Office Address - City______________________________________
Not Applicable

8. Are you a Politically Exposed Person (PEP)? NA Yes NA No

(PEPs are individuals who are or have been associated with a political party/politician or holding any senior role in any ministry/government/state owned
enterprises/judicial body/military/police in India or abroad or those individuals who have any close family members or associates in the said capacity)
If yes, please provide details ___________________________________________________________________________________________________
NA

9. Communication Address NA Current Residential Address NA Permanent Residential Address

Common Proposal Form Version 6.10 Page 5 of 10

 PROPOSAL FORM
Proposal No: 9101930505

10. Current Residential Address NA

_______________________________________________________________________________________________________
_______________________________________________Area/Taluka/Tehsil________________________________________________
NA

City/District __________________________________________________
NA
State ___________________________________________________
NA

Country _____________________________________________________________________________
NA Pin Code ______________________
NA

11. Permanent Residential Address _______________________________________________________________________________________________________

NA

______________________________________________Area/Taluka/Tehsil_________________________________________________
NA

City/District _________________________________________________ State NA

NA ____________________________________________________
Country _________________________________________________________________________________
NA Pin Code ______________________
NA

12.Contact details : Mobile: ISD Code_____NUMBER _______________

8586893839
Alternate Mobile: ISD Code_____ NUMBER ____________
00000000000

Telephone/Mobile Number
wherever available
Residence Number Ph: STD Code. _____ NUMBER ___________
NA Email sushmas92@yahoo.com
_______________________________

13. Proof of Address Submitted Current Residential Address ✔ Permanent Residential Address

14. Address Proof Passport Driving License Voters Identity Card NREGA Card
Bank account or Post Office savings bank account statement ✔ Others (please specify)_________________
Unique Identification (UID)/Aadhaar c

15. Proof of Identity Passport Voter ID PAN Driving License NREGA Card
Unique Identification (UID)/Aadhaar card
✔ Others (please specify) __________________________
NA
Passport/Voter ID/NREGA Card /Driving License/Others Number _______________________________________________________
Passport/Driving License/ Others Expiry Date __________________________________________________
NA

16. Proposer’s Relationship with Life to be Insured NA Self NA Spouse NA Son NA Daughter NA Father NA Mother NA Other _________
17. Mother’s Name Title ✔ Mrs. Ms. Others (Specify) _____________________________________________
First Name _________________________________________________________________________________________________________
SING

Middle Name ________________________________________________________________________________________________________

Last Name ___________________________________________________________________________________________________________

SINGH

18. a) Tax Residency Country ___________________________

India b) Tax Identification Number ___________________________
NA
(TIN numer mandatory for other than Indian)

19. PAN No.___________________________________________

DBNPS8809C (In case PAN is not submitted then FORM 60 is furnished.)

20. Total Insurance Cover (Rs.) ___________________________________________________

NA

21. a) e-Insurance Account Number (eIA) ___________________________________________________

NA

b) Name of the Insurance Repository to which eIA is linked NA CAMS NA CDSL NA KARVY NA NSDL
c) If you do not have an eIA account, would you like to create one? ✔ Yes No
If yes, please name the preferred Insurance Repository ✔ CAMS CDSL KARVY NSDL
d) Do you need a physical copy of the policy document? ✔ Yes No
22. If the proposer is Company/ Partnership Firm/ HUF, following details to be provided: a)Company/ Partnership Firm/ HUF Name: __________________
NA
NA NA NA NA
b) Contact Person/ Proposer/ Nominee/ Beneficiary Name/ Authorized Signatory: Title Mr. Mrs. Miss Ms. NA Other
(specify) First Name ______________________
NA Middle Name _____________________
NA Last Name _________________________________
NA

23. Do you want to opt out of auto-vesting? Yes No

(Auto-vesting implies that Life Assured will become Policyholder on the date of completion of 18 years of age)

Product Details

Mode of Payment Monthly Quarterly Half-yearly ✔ Yearly Single Premium

Plan/Coverage/Rider Name Premium Term Deferment Period Policy Term Coverage Amount Proposed (Rs.) Installment Premium (Rs.)
Canara HSBC Life Insurance Guaranteed Savings Plan
5 10 116105 25563

Total Installment Premium (Rs.) 26125

For Traditional Plans:

I would like to opt for Set-Off Option*: NA Yes NA No

I would like to opt for Plan Option*: NA Endowment with Whole Life Cover Option NA Endowment Option

Common Proposal Form Version 6.10 Page 6 of 10

 PROPOSAL FORM
Proposal No: 9101930505
I would like to opt for Settlement Option*: NA Yes NA No
I would like to opt for Plan Option*: ✔ Guaranteed Savings Guaranteed Savings with Double protection Guaranteed Savings with Premium protection
NA
I would like to opt for Plan Option*: Guaranteed Cashback NA Guaranteed Cashback with Premium Protection NA Guaranteed Income Advantage
NA Guaranteed Single Pay Advantage
I would like to opt for Plan Option*: NA Guaranteed Income {Optional cover NA Premium Protection Cover}
NA Guaranteed Long-term Income {Income period NA 15 Years NA 20 years} {Optional cover NA Premium Protection Cover}
NA Guaranteed Life Long Income {Type of cover NA Single Life NA Joint Life
I would like to opt for Plan Option*: Future Suraksha Income Suraksha {Income period 10 Years 15 years}

I would like to opt for Income Frequency: Monthly Quarterly Half-yearly Yearly

I would like to opt for Plan Option*: NA Flexi Income {Optional cover NA Premium Protection Benefit Option}NA Flexi Care
NA Flexi Savings {Optional cover
Premium Protection Benefit Option}
I would like to opt for Deferred Survival Benefit facility*: NA No NA Yes {if yes, Flexi Income: NA Add 50% of Guaranteed Sum Assured NA Add Guaranteed Income
NA Add Cash Bonus Flexi Care: NA Add Cash Bonus NA Add accrued Guaranteed Additions}
I would like to opt for Plan Option*: iAchieve{Optional cover Payor Premium Protection Cover}iAssure {Optional cover Payor Premium Protection
Cover}Flexi iAchieve Flexi iAssure  Easy iAchieve
I would like to opt for Plan Option*: Plan Option 1 (Endowment) Plan Option 2 (Money Back)
I would like to opt for Plan Option*: Single Life Joint Life#
# if opted, please fill second life questionnaire. : Coverage options for Health First Plan:
I would like to opt for: NA Major Critical Illness Cover {Type of cover NA Level Sum Assured NA Increasing Sum Assured}
{ NA Monthly Income Benefit Option} { NA Return of Premium Option}
I would like to opt for: NA Heart Cover {Type of cover NA Level Sum Assured NA Increasing Sum Assured} { NA Monthly Income Benefit Option}
I would like to opt for: NA Cancer Cover {Type of cover NA Level Sum Assured NA Increasing Sum Assured} { NA Monthly Income Benefit Option}
(Note: Return of Premium Option under Major Critical Illness Cover is available for a policy term of 10 years to 20 years only.
For Unit Linked Plans*:
NA % NA % NA % NA % NA % NA % NA % NA % NA %
Emerging Leaders India Multi-Cap Growth Plus Balanced Plus Large Cap
Equity Fund Equity Fund Equity II Fund Advantage Fund Debt Fund Debt Plus Fund Liquid Fund
Fund Fund

The SFIN (Segregated Fund Index Number) for: Emerging Leaders Equity fund is ULIF02020/12/17EMLEDEQFND136, India Multi-Cap Equity Fund is
ULIF01816/08/16IMCAPEQFND136, Equity II Fund is ULIF00607/01/10EQUTYIIFND136, Growth Plus Fund is ULIF00913/09/10GROWTPLFND136, Balanced Plus Fund is ULIF01013/09/10BLNCDPLFND136, Lagre
Cap Advantage Fund is ULIF02126/03/20NADINDXFND136, Debt Fund is ULIF00409/07/08INDEBTFUND136, Debt Plus Fund is ULIF01115/09/10DEBTPLFUND136 & Liquid Fund is
ULIF00514/07/08LIQUIDFUND136.

Premium Funding Benefit Option Chosen* NA Death Only NA Death Or TPD

You can select your option(s) from the following*

NA Auto Funds Rebalancing NA Milestone Withdrawal Option(MWO) @ NA Safety Switch Option

NA Systematic Withdrawal Option (SWO)@,Choose Frequency of SWO

NA Monthly NA Quarterly NA Half-Yearly NA Yearly
Fund Value to be withrown in a policy Year_____________(1%
NA to 12%)
NA Systematic Transfer Option, Choose Target STO Fund NA India Multi-cap Equity Fund NA Equity II Fund NA Emerging Leaders Equity Fund
NA Large Cap Advantage Fund

NA Return Protector Option, Choose RPO Fund <India Multi-cap Equity Fund/Equity II Fund/Emerging Leaders Equity Fund/Large Cap Advantage Fund>
Target Appreciation _____%
NA (5% to 15% in multiple of 1)
@ Only one of 'Milestone Withdrawal Option' or 'Systematci Withdrawal Option' can be chosen
For Pension Plans:
Annuity option at the time of vesting (maturity) N A (Please mention Annuity option code as mentioned below)

01 Immediate Life Annuity 02 Immediate Life Annuity with return of 03 Immediate Life Annuity with Return of
Purchase Price Balance Purchase Price

Deferred Life Annuity with Return of

Immediate Life Annuity with Return of
05 Immediate Joint Life Annity with 06 Purchase Price
04 Purchase Price on Critical Illness (CI) or
Accidental Total & Permanent Disability Return of Purchase Price Deferment Period 1 2 3 4
(ATPD) or Death 5 6 7 8 9 10 (Years)

a) Amount to be annuitized (as a %age of vesting amount):__________ %(Min 40%)

b) Amount to be annuitized from other insurer (As a %age of A above)____________%(Max 50%)
Other Insurer:_______________________________________________________
* Please refer sales brochure for details on option(s)/ Unit Linked Fund(s) available under a particular product.
1 Applicable for Smart Monthly Income Plan; 2 Applicable for Jeevan Nivesh Plan; 3 Applicable for Jeevan Nivesh Plan, Invest4G, Titanium Plus Plan, Smart Goals Plan, Smart Future Plan, Future Smart Plans; 4
Applicable for Guaranteed Savings Plan; 5 Applicable for Guaranteed Income Plan; 6 Applicable for Guaranteed Income4Life 7 Applicable for Guaranteed Suraksha Kavach 8 Applicable for Flexi Edge
9 Applicable for iSelect Guaranteed Future; 10 Applicable for Easy Bachat Plan; 11 Applicable for Guaranteed One Pay Advantage;
Mode of Renewal Premium Payment

Preference for Renewal Premium Payment

Cheque/Demand Draft ✔ Standing Instructions/NACH Credit Card Others _______________________________
Please fill Payor Questionnaire , Payor KYC and AML Questionnaire if Payor different than Proposer
Common Proposal Form Version 6.10 Page 7 of 10
 PROPOSAL FORM
Proposal No: 9101930505

Bank Details of Proposer for receiving refund or payments

I hereby request you to transfer all refunds / payments arising from the stage of proposal until the completion of tenure of the policy, directly to the bank
account, details of which are provided herein below.
Note - Please submit relevant supporting documents along with the below details
Account Holder Name
sushma
First Name _______________________________________________________________________________________________________

Middle Name _______________________________________________________________________________________________________

sushma
Last Name _______________________________________________________________________________________________________
Canara Bank
Bank Name _______________________________________________________________________________________________________
125002789132
Account No. _______________________________________________________________________________________________________
IFSC Code CNRB0003159
_______________________________________________________________________________________________________
Branch Address VASANT KUNJ DELHI
_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
Account Type Savings ✔ Current NRE NRO

Declaration and Authorization

• I hereby declare, on my behalf and/or on behalf of Life to be Insured, that the above statements, answers and/or particulars given by me are true and
complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of the Life Insured.
• 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 further declare that I will notify in writing any change occurring in the occupation or general health of the Life to be Insured/ proposer after the proposal
has been submitted but before communication of the risk acceptance by the company.
• I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to
be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/
proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the
purpose of underwriting the proposal and/or claim settlement.
• 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/We hereby authorize Company to send me any information relating to my proposals / policies through SMS on the phone number/e-mail address
provided by me.

I have selected the product voluntarily basis my needs and affordability and also hereby agree that any failure on my/our part to notify the Company
•
of the required information or if any of the statements, answers and declarations are found to be fraudulently made or amount to mis-statement, the
said contract shall stand terminated and benefits payable under the Policy will be as per applicable laws including Section 45 of the Insurance Act,
1938, as amended from time to time.

• I authorize the Company to conduct screening/confirmation/ reconfirmation of overall status of my as well as that of the Life to be Insured including the
health status through medical examinations, if required, which may include Laboratory tests, Cardiac, Radiological investigations and other medical
tests including blood tests to detect bacterial/viral/fungal infections. I hereby give my consent to undergo HIV1/2 test by ELISA method. I am aware
that this test is only for screening purposes and not confirmatory for HIV/AIDS.
• I/We authorize the Company to share (within or outside India) my or life to be Insured’s information (regarding the financial, physical or mental health
together with leave records and, employment details from/with (i) Governmental and/or Regulatory Authority,(ii) Insurance Repositories (iii) CERSAI/ other
authetication agencies (iv) reinsurers/hospitals or diagnostic centers/other insurance companies including any past or present employer for underwriting
assessment, claim investigation/settlement, KYC authentication (if permitted), offline verification and policy servicing purpose as per regulatory framework
put in place by the Authority.

• I hereby consent to receive the information from Central KYC Registry or other statutory authority through sms/email on the registered number/email
address.

I/We declare that the premiums paid/ payable are/will not be generated from the proceeds of any illegal means/criminal activities / offences and I/we
•
shall abide by and conform to the Prevention of Money Laundering Act, 2002 or any other applicable laws. I understand that in case of withdrawal of
this application by me post undergoing medicals or part thereof, the Company shall return the first premium deposit without any interest and after
deducting the expenses incurred on the medical test/examination, if any.

Electronically validated through OTP on 16/11/2022 Electronically validated through OTP on 16/11/2022

Signature/Thumb Impression of Life to be Insured Signature/Thumb Impression of Proposer

(Proposer signature required if Life to be Insured is a minor)

___________________
DELHI
Place ______________________________
Date 16/11/2022

Common Proposal Form Version 6.10 Page 8 of 10

 PROPOSAL FORM
Proposal No: 9101930505

Foreign Account Tax Compliance Act ("FATCA")/Common Reporting Standards ("CRS") Declaration (Applicable if the proposer is a US person or is a
tax resident outside of India):
i. I/we certify that (a) I am taxable as a US person under the laws of the United States of America ("U.S.") or any state or political subdivision thereof or
therein, including the District of Columbia or any states of the U.S., or (b) an estate the income of which is subject to U.S federal income tax regardless
of the source thereof. (This clause is applicable only if the proposer is identified as a US person); or (c) taxable as a tax resident under the laws of
country outside India. (This clause is applicable only if the proposer is a tax resident outside of India)

ii. I/We understand that the Company is relying on the information submitted by me for the purpose of determining my status in compliance with FATCA/
CRS. The Company is not able to offer any tax advice on CRS or FATCA or its impact on me. I/We shall seek advice from professional tax advisor for
any tax questions. I/We agree to submit a new form within 30 days if any information or certification on this form becomes incorrect. I/We agree that
as may be required by domestic regulators /tax authorities, the Company may also be required to report, reportable details to CBDT or close or
suspend my policy. I/We certify that I/We provide the information on this form and to the best of my/our knowledge and belief the certification is true,
correct, and complete including the taxpayer identification number.

In case of Thumb Impression, Left Thumb Impression (LTI) for Males, and Right Thumb Impression (RTI) for Females.

Electronically validated through OTP on 16/11/2022 Electronically validated through OTP on 16/11/2022

Signature/Thumb Impression of Life to be Insured

Proposer signature required if Life to be Insured is a minor) Signature/Thumb Impression of Proposer

Date ___________________
16/11/2022 DELHI
Place ______________________________

Declaration by Insurance Intermediary's Representative/ Direct Sales Person/ Agent, etc

I ____________________________ have suggested the present product (s) to the Proposer basis the
assessment of suitability thereof to the needs of the proposer and have fully explained all the features
thereof to the Proposer and he/she has understood same.
Signature of Insurance Intermediary's
Representative/Direct Sales Person/Agent, etc

Vernacular language/Proposal not filled by Prospect/Illiterate Declaration:

I____________________________
NA Son/Daughter of _________________________________,
NA adult and residing at _____________________________
NA
do hereby declare on solemn affirmation as under: I have read out and fully explained the contents of the proposal form in
______________language
NA to Mr./Mrs./Ms. ____________________
NA and he/she has understood the significance of the proposed contract. I have truthfully
and correctly recorded the replies given by the Proposer/Life to be Insured and that the
Proposer/Life to be Insured has affixed the signature/thumb impression above, after fully
understanding the contents thereof. Solemnly affirmed at _____________
NA on ________________
NA

I___________________________(Proposer)
NA hereby declare that I have understood the
questions and answers of the proposal form as explained by Insurance Intermediary's Signature of Insurance Intermediary's
Representative/Direct Sales Person/Agent/Declarant Representative/Direct Sales Person/Agent/Declarant

Electronically validated through OTP on 16/11/2022

Signature/Thumb Impression of Proposer

YOUR COMMUNICATION ADDRESS IS VERY IMPORTANT FOR BETTER SERVICE. PLEASE CHECK IT THOROUGHLY BEFORE SIGNING

Section 41 of Insurance Act, 1938 (as amended from time to time)

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 provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

Common Proposal Form Version 6.10 Page 9 of 10

 PROPOSAL FORM
Proposal No: 9101930505

Section 45 of Insurance Act, 1938 (as amended from time to time)

(1) 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, i.e., from the
date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is
later. (2) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of
commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that 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.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove
that the mis-statement of a 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 of or suppression of a material fact are within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.

(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement
of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, 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:
Provided that 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 to repudiate the policy of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on ground of fraud, the
premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal representatives or nominees or assignees of the insured
within a period of ninety days from the date of such repudiation.
(5) Nothing in this sections 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.

Proposal Acknowledgment Proposal Number: 9101930505

I, Mr/Ms ______________________________ have received the proposal for life insurance along with (Rs.) _______________ from
Mr/Ms___________________________ towards proposal deposit by the way of Cheque/DD No.________________ drawn on ____________________
dated ____________________ with Canara HSBC Life Insurance Company Limited, _______________________ branch. This slip is not your premium
receipt. The premium receipt will be issued only on receipt of premium by the Insurer and upon application of the premium to your policy subject to
acceptance of risk. Receipt of completed proposal and initial premium does not create any obligation upon the insurer to underwrite the risk.Risk under the
policy will not commence till the Insurer accepts the proposal, underwrite the risk and communicates to you the acceptance of the risk on this proposal by
issuing the policy.

Details of Insurance Intermediary's representative/Direct Sale Person/Agent

Name _________________________________
Code _________________________________ Signature
Date ________________________

Canara HSBC Life Insurance Company Limited,

139 P, Sector 44, Gurgaon - 122003, Haryana, India
IRDAI Regd. No 136, Regd Office: Unit No. 208, 2nd Floor, Kanchenjunga Building, 18 Barakhamba Road, Fax: +91
0124 4535099, Corporate Identity No. - U66010DL200PLC248825
Toll free at 1800-103-0003 / 1800-180-0003 / 1800-891-0003 SMS at 9779030003
E-mail us at customerservice@canarahsbclife.in , Visit us at our website www.canarahsbclife.com

Common Proposal Form Version 6.10 Page 10 of 10

 ILN000101
Illustration Number: T014653943
Illustration Version: 1.0.0

Dear sushma sushma

Thank you for showing interest in our Canara HSBC Life Insurance Guaranteed Savings Plan. Based on the details provided by you, and reproduced below, the illustration customised to
your requirements is appended.

Date : 16/11/2022 22:42 Proposal No: 9101930505

Name of Prospect/Policyholder: sushma sushma Name of the Product: Canara HSBC Life Insurance Guaranteed Savings Plan
Age & Gender: 36 Female Tag Line: An Individual Non-Linked Non-Par Life Insurance
Savings cum Protection Plan
Name of Life Assured: sushma sushma
Unique Identification 136N066V02
Age & Gender 36 Female No:
Policy Term 10 Years GST Rate(Year 1) 4.5%
Premium Payment Term 5 Years GST Rate(Year 2 2.25%
Amount of Instalment Premium Rs. 25000 onwards):
Mode of Payment of Premium: Yearly

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy

Policy Details: Premium Summary

Policy Option Guaranteed Savings Base Plan Riders Total Installment Premium
Option
Instalment Premium Without GST Rs. 25000 - Rs. 25000
Sum Assured: Rs. 116105
Instalment Premium in First Year with GST Rs. 26125 - Rs. 26125
Sum Assured at death: Rs. 275000
Instalment Premium 2nd year onwards with GST Rs. 25563 - Rs. 25563
(at inception of the policy Rs)

Page No. 1 Production Release Channel Name: CNR Version 29.0.0 N Illustration Number:T014653943
 ILN000102

(Amount In Rupees)

Guaranteed Non Guaranteed

Policy Year Single/ Annualized Survival Benefits/ Loyalty Other Benefits, if any# Maturity Benefit** Death Min Guaranteed Special Surrender
Premium Additions* Benefit Surrender Value Value
1 25000 0 2000 0 275000 0 0
2 25000 0 6000 0 277000 15480 23889
3 25000 0 12000 0 281000 27930 41315
4 25000 0 20000 0 287000 53840 61653
5 25000 0 30000 0 295000 79000 88629
6 0 0 30000 0 305000 92400 102515
7 0 0 30000 0 305000 102550 113555
8 0 0 30000 0 305000 112700 123018
9 0 0 30000 0 305000 122850 135635
10 0 11611 30000 157716 305000 123000 149830

*Loyalty Additions refers to Guaranteed Loyalty Addition paid on Maturity

#Other Benefits refers to the total of the Accrued Guaranteed Yearly Additions till date. Guaranteed Yearly Additions are calculated as % of cumulative Annualized Premiums added during

Premium Payment Term

**Maturity benefit includes Guaranteed Sum Assured on Maturity plus Accrued Guaranteed Yearly Additions plus Guaranteed Loyalty Addition

Notes: Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any and Goods & Service Tax

Page No. 2 Production Release Channel Name: CNR Version 29.0.0 N Illustration Number:T014653943
 ILN000103

The illustration should be read in conjunction with the important notes given below & on subsequent page(s).

Important Notes:

1. Guaranteed Maturity Benefit = Guaranteed Sum Assured on Maturity + Cumulative Guaranteed Yearly Additions + Guaranteed Loyalty Addition
2. a) Guaranteed Savings Option: The Death Benefit is the benefit payable on death of the Life Assured, which is Sum Assured on Death plus Guaranteed Yearly Additions accrued till the date
of death. Where Sum Assured on Death is defined as Higher of (11 times the Annualized Premium or Guaranteed Sum Assured on Maturity or Absolute amount assured to be paid on death or
105% of the Total Premiums Paid till the date of death),
b) Guaranteed Savings with Double Protection Option: The Death Benefit is the benefit payable on death of the Life Assured, which is Sum Assured on Death plus Guaranteed Yearly
Additions accrued till the date of death. If death of the Life Assured is due to an accident, an additional amount equal to the ADB Sum Assured will be paid to the Nominee. Where Sum Assured
on Death is defined as Higher of (11 times the Annualized Premium or Guaranteed Sum Assured on Maturity or Absolute amount assured to be paid on death or 105% of the Total Premiums
Paid till the date of death),
c) Guaranteed Savings with Premium Protection Option: The Death Benefit is the benefit payable on death of the Life Assured, which is Sum Assured ion Death. In addition, future premiums
are not payable and on maturity, Guaranteed Sum Assured on Maturity plus Accrued Guaranteed Yearly Additions and Guaranteed Loyalty Addition, will be payable. Where Sum Assured on
Death is defined as Higher of (11 times the Annualized Premium or Guaranteed Sum Assured on Maturity or Absolute amount assured to be paid on death or 105% of the Total Premiums Paid
till the date of death)
3. Minimum Guaranteed Surrender Value / Special Surrender Value is payable at the end of the policy year.
4. Annualized premium mentioned excludes rider premiums, underwriting extra premium and loadings for modal premiums, if any, as well as excludes Goods and Services Tax & applicable cess
(es)/other levy, if any.
5. Installment premium mentioned above is inclusive of underwriting extra premium & loadings for modal premium, if any.
6. A Policy shall acquire lapse status if the Policyholder fails to pay due premium within the Grace Period in the first 2 consecutive Policy years. In such case your Policy will lapse at the expiry
of the grace period and the insurance cover will cease immediately. No benefit shall be payable upon death or upon your request for termination of the Policy or on the expiry of the revival
period.
7. Guaranteed Yearly Additions will be calculated as a percentage of cumulative Annualized Premium(s) paid and vary by the Premium Payment Term. Guaranteed Yearly Additions will accrue
at the end of each Policy Year throughout the Premium Payment Term, provided all premiums due till the end of that Policy Year have been paid.

Other points to note:

1. Guaranteed Yearly Addition (s) and Guaranteed Loyalty Addition will be payable provided all due premiums are paid and Policy is in-force.
2. This is a traditional plan intended for long term savings and benefits. It is strongly advised that the Policy should be continued throughout the defined Policy term to realize the full benefits.
Early exit should not be opted for unless there is no other alternative available, as it will impact the Policy value. If premiums are discontinued after payment of at least first 2 consecutive Policy
years’ premiums then the Policy will acquire a Paid-up value. You will receive this Paid-up value on death or on maturity, provided you have not surrendered or revived the Policy.
3. Your policy will acquire a guaranteed surrender value (GSV) after payment of at least first 2 consecutive policy years’ premiums. However, the Company may offer a special surrender value
(SSV), and higher of {GSV or SSV} will be paid on surrender. The Illustration shows both the GSV as well as the current SSV payable on surrender of the policy. SSV scales may be revised in
the future by the Company with the prior approval of the Authority.
4. You may be entitled for tax benefits under Section 80C and Section 10(10D), as per the Income Tax Act, 1961 as amended from time to time.
5. The premium shown is for a healthy individual. Your application will be assessed as per Board approved underwriting Policy of the Company. Basis underwriting, it may result in extra
premium to be paid, which shall be borne by you.
6. For more details on product features and terms and conditions please read sales brochure or sample Policy contract carefully before concluding a sale.

Disclosures

Corporate Agent will receive commission basis the premium payment term (PPT) of the policy from the company for this transaction:-
5 years PPT :- 15% commission on 1st year premium, 5% from 2nd year onwards.
IRDA regulations do not permit Corporate Agent or its employees to pay such commission, whether in part or whole, as an inducement to any person to take out or renew or continue an
insurance policy of any kind.

I,...................................................(name), have explained the I,...................................................(name), having received the

premiums, and benefits under the product fully to the information, with respect to the above, have understood the

prospect/policy holder. above statement before entering into the contract.

Place:

Date: Signature of Agent/Intermediary/Official Date:16/11/2022 Signature of

Prospect/Policyholder.Electronically validated through OTP on

16/11/2022

Page No. 3 Production Release Channel Name: CNR Version 29.0.0 N Illustration Number:T014653943
Version 2.0

Guaranteed Savings Plan: Key

Information Document (KID) There is no compulsion or requirement to take this Life
Insurance Policy as a condition/ part of a bank loan.

Other important aspects that you must know:

• In the unfortunate event of death of the Life Assured,

1. For Guaranteed Savings Option & Guaranteed Savings

You have the
to with Double Protection Option

2
choose from Sum Assured on Death, plus Cumulative Guaranteed
multiple premium Yearly Addition(s) added, as on date of death.
payment terms If you have opted for Guaranteed Savings with Double
(i.e. 5/ 7/10 with
policy term ranging
Protection Option and death of the Life Assured is due
from 10 to 20 to an accident, an additional amount equal to ADB Sum

1
years). Guaranteed Yearly Assured will be paid.
payable on maturity, Additions will accrue at 2. For Guaranteed Savings with Premium Protection Option

3
provided all due the end of each policy year
premiums have been throughout the premium
paid. payment term, provided
all due premiums till the
end of that policy year have
been paid.
• Sum Assured on Death
• All future premiums (if any), need not be paid and
the policy shall continue to be in force for the remaining
Policy Term. The policy will also continue to accrue
Guaranteed Yearly Addition(s). The policy cannot be
surrendered/ terminated before reaching maturity

7
• On maturity - Guaranteed Sum Assured on Maturity
Important plus Guaranteed Yearly Addition (s) plus Guaranteed
aspects about Loyalty Addition

7
Loans
Provides liquidity
Guaranteed Where
a) 11 times Annualized Premium b.105% of Total Premiums
once the policy acquires Savings Plan Guaranteed
Paid as on date of death b) Guaranteed Sum Assured

4
surrender value. Loyalty Addition
is added into your on Maturity c) Absolute amount assured to be paid on
policy at the end of death.
the policy term if all
due Premiums have • In case you stop paying the premiums after paying for
been paid. the policy will become paid-up and

In case of
• Policy acquires a Guaranteed Surrender Value (GSV)
surrender/ after payment of atleast first 2 consecutive years premium
non-payment of

6
premiums, the Value (SSV), and higher of GSV and SSV will be paid on

5
Provides life surrender.
will be reduced cover for the entire • Prem
that you would term while you pay
have otherwise premium only for a
received on policy limited period.
change in tax laws. Please consult your tax advisor for
continuance. details.
• Applicable taxes including good and service tax, as per
government regulations, will be levied additionally and
are to be borne by the Policyholder.

Policy Discontinuance & Revival:

• years. No policy benefits are payble in such cases.

• 5
For details on the product features, please refer to the product brochure.

IMPORTANT DISCLOSURE REQUIREMENT:

Please provide correct and complete details, including information on all medical ailments such as diabetes, hypertension, heart diseases, cancer, etc. in the
proposal form, otherwise, there is a risk of your policy benefit/ claim being denied.
I have been briefed on the benefits and features of Canara HSBC Life Insurance Guaranteed Savings Plan. I have understood the information and risks
associated with this plan. I confirm that my selection of the above policy is in keeping with my life insurance/investment objectives I have briefed
__________________________________________ in ______________________________________ language on the benefits and features of this
insurance plan.

Name: Signature: Date:

Code: Proposal Number:

IMPORTANT INFORMATION:
This is the Key Information document about the Guaranteed Savings Plan and it doesn’t replace the full policy terms and conditions (which you should read
carefully on receipt). Guaranteed Savings Plan is an Individual Non-Linked Non-Par Life Insurance Savings cum Protection Plan intended for

regular savings and long case of surrender, the surrender value available may be lower than the premiums paid.Hence, we recommend that
you pay your premiums. regularly and continue the policy till maturity. Early surrender should not be opted for unless there is no other
alternative available, as it will impact the policy value and intended goals may not be realised

Purchase of any insurance products by a bank’s customer is purely voluntary and is not linked to availment of any other facility from the bank.
For more details on risk factors, terms and conditions, please read the sales brochure carefully before concluding a sale. You can also speak to your sales representative, or
visit our website www.canarahsbclife.com.
There are restrictions on requests of Top-ups, Increase or Decrease in Sum Assured, Changes in Funds (including Fund Switch and Redirection), Revival of Policies, any
request that results in change of premium or policy feature while the customer is in the US. The Company reserves the right to restrict any other policy servicing request
basis the applicable US Law.
You will shortly re
proposed Life Insurance plan.
Canara HSBC Life Insurance Guaranteed Savings Plan (UIN: 136N066V02)
The information provided here is indicative of your policy terms and conditions. The Insurance products are offered and underwritten by
Canara HSBC Life Insurance Company Limited (formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd)
(IRDAI Regn. No. 136) having its head office at 139 P, Sector 44, Gurugram – 122003, Haryana (India).
 Deposit Acknowledgement
Date : 16/11/2022

Dear sushma sushma,

Proposal Number : 9101930505

Life To Be Assured : sushma sushma

Plan : Guaranteed Savings Plan

Amount Received : INR 26150.00

Thank you for your interest in Canara HSBC Life Insurance Company Limited.

This is with reference to your application dated 16/11/2022 regarding your life insurance application no 9101930505.We
wish to acknowledge the transaction for payment of premium, with respect to your application vide receipt number
D113404392.However, the premium paid is subject to realization. Your application is under process and you would receive
formal communication on this shortly.

Thank you for continued patronage with Canara HSBC Life Insurance Company Limited and giving us an opportunity to
serve you.

In case you need any further assistance in this regard please do get in touch with our Resolution Centre.Resolution Centre
Toll free no- 1800-103-0003

Note: This is a computer generated letter and does not require signature

Canara HSBC Life Insurance Company Limited,

139 P, Sector 44, Gurgaon - 122003, Haryana, India
 AML Addendum
(To be filled in for Proposer)

9101930505

sushma sushma

Not Applicable

e)

2. Have you changed your country / city of residence in last 12 Months Yes ✔ No
(i) If answer Q2,

Q2,

Q3,

4.
1 2 3 4
India NA NA NA
Country of tax residence
(if taxes are/are also filed outside India)
NA NA NA NA
Tax Identification No.

DBNPS8809C

Aadhaar,

Electronically validated through OTP on 16/11/2022

Date : 16/11/2022

Signature
(Proposer / LA / Payor)

UW/AMLADD/Version 1.1
 Banking/ Spouse / Nominee details Questionnaire

Application No.: 9101930505 Name of the Insured: sushma sushma

Bank Relationship Questionnaire

S.no Reflexive questions Answers

1 Banking Since NA

Spouse Questionnaire

S.no Reflexive questions Answers

1 Spouse Occupation NA

NA
2 Spouse Income
3 Spouse Insurance NA

Nominee Relationship Details

S.no Reflexive questions Answers

1 Relationship with Life Insured Father

2 Reason for Nomination NA

I/We hereby declare that the above statements and answers are true in every respect and I/We agree for
treating this to be part of the Proposal Form.

Name of Insured sushma sushma

 Comprehensive Medical Questionnaire

Application No.:9101930505 Name of the Insured: sushma sushma

I/We hereby declare that the above statements and answers are true in every respect and I/We agree for treating this to be part of the
Proposal Form.

Name of Insured
ABC
 Declaration
To be duly filled by the Life insured and (Spouse, if Spouse Rider is taken)

Please tick the correct option and provide details in the space
S.No given below along with question reference if your answer is yes
to any of the below questions. Life Insured Spouse
Yes No Yes No
Have your family members travelled to Countries outside India
1
in the past 2-3 months? If yes please provide name of the ✔
country, purpose and duration of stay and date of return.
LA Details:
Name of the country : NA
Purpose:
NA
Duration of Stay: NA
Date of Return: NA

Spouse Details:
Name of the country : NA
Purpose:
NA
Duration of Stay: NA
Date of Return: NA
Did you have to or advised to self-isolate as a result of travel
2 OR for any other reason without symptoms (e.g. contact
tracing) due to COVID-19 (excluding mandatory government ✔
orders to remain at home due to lockdown) ?

Have you come in contact with any person suspected OR

3 ✔
confirmed to have ‘Corona virus’ OR tested positive for “Corona
Virus? If yes, pl provide details
Provide details for LA:
NA

Provide details for Spouse:

NA

Are You currently or any of your family members (living together)

having symptoms of COVID-19 (such as any flu like symptoms cold,
4 persistent cough, running nose, headache, fever, shortness of ✔
breath, breathing difficulties, nausea, nausea, vomiting , diarrhea
etc.) or Advised to undergo COVID test OR Awaiting test result of
 COVID 19 OR self-isolated with symptoms on medical advice ?
I f yes, mention details: Relationship with life assured/Exact
Diagnosis/Date of Diagnosis:

Life Assured Details:

Relationship with LA: NA
Exact Diagnosis:
NA

Date of diagnosis: NA

Spouse Details:
Relationship with LA: NA
Exact Diagnosis:
NA

Date of diagnosis: NA
Have you ever had a positive COVID-19 test? If yes, when was this?
5 ✔
Please share reports
LA Details:
Date: NA

Spouse Details:
Date: NA
If answer to 3, 4,5 is Yes, then answer below
Did you require admission to hospital? If yes,Did you require a stay
6 in High-dependency unit (HDU), intensive care unit (ICU), intensive
treatment unit (ITU) or critical care unit (CCU) admission?
If yes, did you require the support of a ventilator?

6a) Did you require a stay in High-dependency unit (HDU),

intensive care unit (ICU), intensive treatment unit (ITU) or
critical care unit (CCU) admission?

6b) Did you require the support of a ventilator?

 If answer to 3, 4,5,6 is Yes, then answer below
7 Have you made a full physical function recovery, able to perform
your normal occupational or daily duties, without any ongoing
symptoms or restrictions (i.e. shortness of breath or fatigue)?

If yes, when did you make a full recovery?

LA Details: 7a) When did you make a full recovery?

NA

Spouse Details: 7a) When did you make a full recovery?

NA

Space for Details: ______________________________________________________________________

NA

_____________________________________________________________________________________
Electronically validated through OTP on 16/11/2022
sushma sushma
Name of the Life Insured:____________________ Signature______________________
NA
Name of the Spouse :_______________________ Signature______________________
16/11/2022
Date:__________________________ DELHI
Place:________________________