MAX LIFE INSURANCE CO.

LTD

Annexure A-NRI/PIO/Foreign National Questionnaire

(All fields are mandatory)

Proposal No. ________________

Name of the Insured: __________________

Name of the Proposer (if different): _________________

Sec Information required Proposer Information Insured Information

1 a. Your Nationality : ________________ ________________

b. Your Country of Birth : ______________ ________________

2 Passport details:

a. Passport Number : ________________ ________________

b. Passport issuing country: ________________ ________________

(Kindly attach attested copy of passport showing ________________ ________________

latest entry to India)

3 ________________________ ________________________
a. Current Country of Residence
b. Full address in the country of residence ________________________ ________________________
overseas:
________________________ ________________________
c. Address Type (Tick appropriate)
Residential or Business
Residential
________________________ ________________________
Business
Registered office ________________________ ________________________
Unspecified
d. Telephone No. not pertaining to India : ________________________ ________________________

4 Date of latest entry to India :

5 Country/Countries visited frequently :

6 a. PAN (India) ________________ ________________

b. Foreign Tax Identification No (Indian Pan
Equivalent) allotted by tax resident ________________ ________________
country. (If filling tax in more than one ________________ ________________
country , kindly provide TIN of all
countries of tax residence)

Max Life Insurance - AS_18032016_VER1.3

7 a. Unique Identification Number (UID) ________________ ________________
b. UID issuing country
________________ ________________

8 a. Type of Visa:

(Dependent/Working/visiting) ________________ _______________

b. Visa Valid till: ________________ _______________

9 Country of residence as per tax laws ________________ ________________

(If more than one country of tax residence,
kindly provide information on all countries of tax ________________ ________________
residence)

I/We hereby declare that the above statements information is correct in all respects and may be
used for all purposes including compliances and understand that it is my responsibility to report
the changes, if any, to Max life within 2 weeks of occurrence of such change.

#Submit Pan Card / Election Id/ Driving license/ID card/Passport/Aadhar/ any other govt agency
issued document

Signature of Proposer: _____________________________

Signature of Insured: ______________________________

(If major and different from Proposer)

Place: _____________________________

Please note: Customers belonging to Tax exempted countries and where PAN/ TIN number is not
available, should submit unique identification number of that country.

Max Life Insurance - AS_18032016_VER1.3