Shriram Life Insurance Company Limited

Head Office, Ramky Selenium, Plot No. 31 & 32,5th & 6th Floor, Beside Andhra Bank Training Centre,
Financial District, Gachibowli, HYDERABAD-500032. CIN: U66010TG2005PLC045616

CUSTOMER MANDATE CUM DECLARATION FORM FOR NEW BUSINESS

Proposal No: ________________ (to be filled in by Office) Place: ____________________________
Product Name: _______________________ Date: _/ _/ ______
To,
Shriram Life Insurance Company Limited.
Proposer Name:

Life Assured Name:

Proposer Mobile No E-mail Id: ____________________________________________

I have proposed for a policy of life insurance from Shriram Life Insurance Company Limited (Company) and have accordingly made a proposal
for insurance. Soft copy of the proposal form is filled as per my instructions and requirem ents and read out to me by the Agent / Employee
(Name): ____________________________________________ and the supporting documents provided by me have been obtained by the said
Insurance Agent. This proposal needs to be considered as my mandate to the agent and the company.
List of documents (proofs) submitted as requirements to issue the Policy are as follows:
Photo Identity Age Address Bank A/c NACH Other Documents (Please specify the type of documents submitted)

Please mark ( ) on the documents submitted.

I hereby declare that I have disclosed all the existing life Insurance policies issued to me by Shriram Life Insurance Company Ltd and all other Life Insurance
Companies. I also declare that I have also disclosed all the proposals currently submitted by me to all the life Insurers. I agree that Shriram Life Insurance
co Ltd reserves the right to take appropriate action and initiate proceedings in case of any non-disclosure or misstatements on my part.
I/ We understand and agree that by submitting this declaration through the mobile application, I/ We will be bound by such statements/disclosures of
material facts in The same manner and to the same extent, as if I/We have signed and submitted a written proposal for insurance to the Company.
I/We fully understand the nature of all the questions including health related questions and the importance of disclosing all material information while
answering such questions in this application & the suitability analysis disclosures to the Company. I/We declare that answers given by me/us to all the
questions in the above mobile application including the information given to Shriram Life Insurance Company Limited as to the state of health & habits
of the life/lives to be assured are true and complete in every respect.
I/ We undertake to notify Shriram Life Insurance Company Limited ("the Company") of any change in the information with respect to the life to be assured
subsequent to the submitting of this application and before the acceptance of the risk by the Company.
I/We understand that any mis-statement or suppression or non-disclosure of material information submitted or where the Company is not notified of
any change as mentioned above, the policy contract shall be treated in accordance with Sec 45 of Insurance Act 1938 as amended from time to time.
The Company reserves the right to accept, reject, decline or offer alternate terms on this application for life insurance. In case proposal has been cancelled
the proposal deposit amount paid by me shall be refunded to me by reverse payment, in the same account from where payment was made by me.

Proposer Signature: ______________________________________ Life Assured Signature: ________________________________________

VERNACULAR DECLARATION
Declaration by the person filling in the form (In case form is filled up / signed in a language different from that of the Proposal Form)
“I hereby declare that I have fully explained the above questions to the proposer and I have truthfully recorded the answers given by the
proposer/life assured.”
Name of the Declarant: _______________________________________ Address of the Declarant: _____________________________________
______________________________________________________________________________________________________________________
“I certify that the contents of the form and documents have been fully explained to me by (Name, Designation, and occupation)
Mr / Mrs.: ________________________________________________________ and I have understood the significance of the proposed contract.

Signature or thumb impression of the person whose life is proposed to be assured:

In case the Proposer is illiterate, his/her thumb impression should be attested by a person of standing whose identity can easily be established,
but unconnected with the insurer and this declaration should be made by him.
“I hereby declare that I have fully explained the above questions and contents of the proposal form to the proposer in _____________________
language, and that the proposer has affixed the thumb impression above after fully understanding the contents thereof.”
Name of the Declarant: ________________________________________ Signature of Declarant (in English): _____________________________
Address of the Declarant: ___________________________________________________________

Customer Declaration Form

 'fLssRrnavr
t.-- ,., ,..ur..-r* 3
",..,.. . ur\,{RN Oate

-fick ---ase'-
Sponso. B€nk Code Uuiry Cods

UlrJe h€roby au$orize Shriram Life lnsurance Co. Ltd ro d€b (rick / ) 58D CAtr CCtr 58-NREtr SB-NROtr OtherE

Bank a/c number f fTfT-fT-fTfT-f fTfT_rTfT-fTf

wilh bank

an afircirnl of Rupees
IIIIII
Nad. o, custoheE b.nk IFSC orMlCR IIII
{
FREQUENCY E uoHrnlv trory trH.y E y,t Z & a when presenbd DEBITTYPE EFixedAmount Z MaximumAmoudt

Rafuranco I Mobile No.

R€ferEnce 2 EmaillO
I agr€€ br the debit of mandat6 processing cnaE€s by ho bank whom I am authorizing to debil my account as p6r latest sdledulq of dral!€s of the bank.

PERIOD
c ),1
!-Tilll S€namE Pnmaryr@unl holda SlgnatuE Pnmary A@iit holder SrqnatrE Pnn.ry Accolnt holde

b x x x x x E-El,.
o Z ,no,*-no 1, 2, 3.

. n6 b b cdim lirt th. d6.ffin nB !..i cndury Ead, A nd€ by nE/us. I an atib.rtilg !16 Lls.r $t/t / cdFr.L b d.bn ny ac.urit
'rlddsbod

lnslruclions lo lill Mandale:

rr r Service Provider generatsd Scheme/ Plan reference number.
is auto
generated during mandate creation and is
UMRN
mandatory to be updaled during amendment and Cancellation of
* Tick on boxto selectfequency oltransaclion.

mandate. (Maxlmum lengh - 20Alpha Numeric Characters) + Validity 0f mandate wih dates in DDntltfl\rY\ry format Start date

.! Date in DD/Mttil/YY\.Ylormat.
!s mandalory.

.:. Name of Service Provider.

* Names ol customer/s and signatures as well as seal of Company
(wherE required). (Maximum lengh 0f Name - 40 Alpha Numelic
,, Tick 0n box t0 select type ol actions to be initiated & {c to be CharacteE)
aflected n Undertaking by customer& maillD ofcustomer.
n Customefs Bank name, brianch and account numbe[ left padded rr 10 digitmobile numberof customer.
wi$ zeroes. (Maximum length -35Alpha Numeric Characters)
Kindly ignor8 0te bclou 2 poinls. (Alteadyfilled ln)
.:. IFSC/MICR code o, customer bank. (Muimum lengh -11 Alpha
IFSC / MICR code, lett padded wi$ zeroes
1. Sponsor Bank
Numeric Characters)
where Necessary Ouimum length{1 Alpha Numeric
.i Amount payable pertransaction in words. Characters)
.! Amount in liguBs, similar l0 the amount mentioned in words. 2. t tility Code ol he Service Provider. (Maximum lengfi -18
(Maximum lengh -13 digit Numeric, in paise) Alpha Numeric Characters)
.l Service Providergenerated c0nsumer relerence number.

DGclaralion
l/1leherebydeclarethatheaboveinlormationiscorrectandcomplete.liveacknowledgethatUWehayhaveread,understoodandagreeto
be bound byhe'Terms and Conditions" detailed in this application form, as are cunenfly in effectand as may be amendedfrom timetotime.
l/We wish to avail ol lhe NACH facility and here by express my/our unconditional consent of debit my/our insurance premium from above
menlioned accountthrough NACH. ll'VVe authorise he bankto honour all such instructions. l/live authorize the representative ol the company
to getthis mandate verified and registered with you. Vertfication charges (tfany) may be charged to my/our account.

Debit Date :............/.........../...

x
Cu.lom.. AclaEwledg.m.nt Gopy ! I!II
Date &andr STAITP
Application Number o. Polkry Number a
TIME
Policy Holder Name Customer Relationsh ip Ofc€r

Nol6: t. Request for activatiro ofAuto Oebit facilily has to b€ submittod aleast 30 dal/s prior to the nsxl prqmlum du€ clate at the n€al€st Shiram Lif6 brandl.
2. Requ€st ior de-adivalion ofAuto Dobit iacility has to b€ subrhitled ateast 15 days pdor lo lhe next pemium due date at tle nearcst Shrirarh Life br.ndr.