MAX LIFE INSURANCE COMPANY LIMITED Proposer

Regd Office : 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachur, District Nawanshar,
Punjab-144533 Head Office: 11th & 12th Floor, DLF Square, Jacaranda Marg, DLF City Attach Recent
Phase-II ,Gurugram - 122 002 Photograph
Only if payor is
different from
proposer and AFYP
PROPOSAL FORM is > Rs 10,000/-
Proposal Number: 323022707 GO/CA/Broker Code: 481310
Combo Proposal Number:
All proposal forms must have proof of Age, identity, Income and address of proposer and life insured (current, permanent, if applicable)
• Insurance contract is based upon utmost good faith, please disclose all the information correctly and completely.
Objective of Insurance Keyman Individual
✔
In case of Keyman Policy, Payor should be same as the Proposer.
Do you have Max Life Insurance Policy or have you ever applied for one? No Policy No:
PERSONAL DETAILS
Nominee(Fill No. 1-5 only)
Proposer / Life Insured
✔
1. Title Mr Ms Dr Mrs Mr Ms Dr Mrs Master

First Sridhar Yagavi

2. Name Middle
Last P S

3. Father's/ First Palanisamy Subramaniam

Husband's
Name Last

4. Gender Male Female Male Female

5. Date of Birth 24/11/1993 12/03/1996

6. Relationship to Life Spouse Parents Others

Insured/Nominee Brother

7. Nationality Indian NRI

8. Marital Status Single Married Divorced Widow Divorced Married Single Widow(er)

Graduate High School Illitrate Post Graduate

9. Education Qualification High School Graduate Post Graduate Professional
Primary School Professional

CRPF Defence Oil and Natural Gas

CRPF Defence Merchant Marine
10. Industry Type Merchant Marine Mining Others Agro
Mining Oil & Natural Gas Others
Industry
11. Defence/CRPF
a. Place of Posting
b. Rank
c. Which branch of Armed Forces
are you in?

d. Are you involved in Yes No Yes No

hazardous activities? e.g.
Aviation, diving,parachuting,
bomb disposal,special
services group etc?

Salaried Professional Self Employed from Home Agriculture House wife Laborers Others
12. Occupation Self-employed Housewife Retired Student Others Professional Retired Salaried Self Employed
Student
13. Job Title Owner
14. Nature of
Office And Field Work
Duties/Business
15. Name of Employer KTS Vegetables

16. Annual Income(Rs.) 500,000.00

17. Are you/your Nominee a Politically Exposed Person (PEP)? Yes No
If above Question "Yes" then answer below:
a. Which of the following persons is PEP (Tick as applicable) Life insured Family member of life insured
Specify:
b. Please specify the extent of Political involvement:
i. Political Experience (Years) 0
ii. Affiliation to Political Party
iii. Role in Political Party Social Worker MLA MP Others
iv Portfolio Handled
v. Whether Party in Power Yes No
c. Whether the concerned PEP has ever been posted in foreign office/portfolio? Yes No
Specify:
d. Please specify all sources of income of concerned PEP?
e. Has the concerned PEP ever been convicted or is under any investigation for any crime punishable by 3 or more years Yes No
of imprisonment?
Specify:
18. Do you wish to opt for this policy under e Yes
Insurance
19. e-Insurance Account No. (if available): 0 Repository Name :

20. Preferred Insurance Repository you would like to have your E-Insurance Account with (if you do not have an existing account)
CAMSRep CIRL Karvy NDML SHCILIR

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1.1
 21. Communication Address
House No/Apt Name/Society SO Palanisamy
Road/Area/Sector No 81, Raja Street
Landmark Perundurai
City Erode
Pin Code 638002 State/UT TAMIL NADU Country India
Mobile1 9688889911 Mobile 2 9842866336 STD Code Landline
E-mail (for communication and
p.sridhar.pri@gmail.com
receipt of Policy)
AadharNo Addition in Address
22. I authorize Max Life Insurance to send all communication by E-mail and execute the transactions through internet. Yes No
23. Permanent Address
House No/Apt Name/Society No. 81, Raja Street
Road/Area/Sector Perundurai
Landmark
City ERODE State/UT TAMIL NADU Country India
Pin Code 638052 STD Code Landline
Mobile 9688889911
E-mail (for communication
p.sridhar.pri@gmail.com
and receipt of Policy)
24. Guardian (If nominee is under age 18) name an adult (the“Guardian” ​) to receive the policy proceeds.

Relationship to Life Insured

COVERAGE INFORMATION-TYPE OF COVERAGE
Premium Paying
Name of the Product Coverage Term Sum Assured Premium (Rs.) GST*
Term
Max Life Online Term Plan Plus -
50 50 Rs. 10,000,000.00 7,700.00 1,386.00
Sum Assured

Total Premium: 9,086.00 (2 month premium in case

Premium without GST* and Cess: 7700 GST* and Applicable Cess: 1,386.00
of Monthly mode )

Death Benefit Option: Option 1-Sum Assured Option 2-Sum Assured Plus Level Monthly Income Option 3-Sum Assured Plus Increasing Monthly Income

MODE OF PAYMENT: Annual Half Yearly

Life Stage Benefit: Yes Renewal Premium by: Cash
Monthly Quaterly One Time
Is payor different from proposer/insured ? No
If Yes, Please provide Payor Details Name Relationship with Insured

Address
Annual Income of
PAN No. : DOB
Payor
1. Permanent Account Number(PAN) Form 60-61 ENLPS2570F
Note: TDS may be applicable for resident policyholder, in accordance to provisions of section 194DA under Income Tax Act, 1961.
TDS would be deducted @2%. In case valid PAN is available otherwise 20% will be deducted as per prevailing provisions of law.
a. I do not have PAN Number as I have applied for PAN
b. I am Exempt from the requirement of PAN under the following provision of the IT Act, 1961:
Section 139A:Neither my income nor the income of any other person in respect of which I am asessable under the act was in excess of the
maximum amount not chargeable to income tax in any previous year.

Section 114C: I am having only agricultural income and am not in receipt of any other income chargeable to income-tax.
2. Are you a Max Life Agent Advisor or an employee of a Max Group Company/Corporate Agent? Yes No
3. Is this application under Joint Application discount ? Yes No Joint Application No:- Relationship with Applicant:-
4. Source of Funds Salary Agriculture Professional Business Other Income specify

*GST includes CGST and SGST/UTGST or IGST which ever may be applicable.
INFORMATION OF LIFE INSURED
1. Do you have any Life, Disability, Critical Illness or Health Insurance policy issued/pending/lapsed with or any other Yes No
insurance company?
Name of Insurance Company Total Sum Assured Policy Number Status: Pending/Issued/Lapsed Type of Policy (Life, Health, CI, Disability)

Others 500000 Issued Health

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 2. Has any proposal/reinstatement for life or health Insurance ever been refused, modified, postponed or offered with extra Yes No
premium (Reason, Month, Year and Name of the Insurance Company)? Give details below
Name of Insurance Company Total Sum Assured Policy Number Status: Pending/Issued/Lapsed Status: Type of Policy (Life, Health, CI, Disability)

3. Do you participate in any hazardous activities as part of your Occupation/ Sports/ Hobby ? Yes No
,
4. In the next 1 year, do you intend to travel or reside abroad for more than 4 weeks? Yes No
Country Cities Purpose Duration of Stay in Weeks

5. Have you ever been convicted or are you under investigation for any criminal charges? Yes No
Details of Charges and Conviction Outcome
6. For Female Life Insured
a. Spouse Detail: Occupation: Annual Income: Insurance Amount:
b. Full Name Prior to Marriage (If there is a name change post marriage):
c. Are you pregnant? Yes No If yes,how many months:
MEDICAL INFORMATION
1. Family History: Has any of your family member (parents and sibling) ever been diagnosed before the age of 60 with Yes No
Diabetes, Hypertension, Kidney Failure, Cancer, Heart Attack or any Hereditary disorder? If "Yes" ​, give details.
Family Details Proposer Life Insured

Family Member Age at Diagnosis Disease/Medical Problem

Age at Diagnosis Disease/Medical Problem

2. Proposer Life Insured

Height 170 Ft Inch OR Cm
Weight 56 Kg Kg
If your weight has changed by more than 5 Kgs in the past one year, give reason.
3.Have you ever been investigated/diagnosed or treated for any of the following? Check all that apply
High Blood Pressure Chest Pain Heart Attack Stroke Any Other Heart Condition

High Blood Sugar Diabetes Thyroid Any Other Hormonal Disorder

Asthma Tuberculosis Any other Respiratory Disorder

Cancer Tumour/Malignant Growth Leukemia Any blood disorder

Any Stomach or Intestinal Disorder such as Recurrent Indigestion or Ulcers Jaundice or Any Liver Disorder Any Kidney Disorder

Mental/Psychiatric Ailment Disease of the Nervous System

Any Ailment of Bones/Joints/Limbs Any Disorder of Spine Ear,Eye,Nose Any Disorder of Muscle
Have you ever been diagnosed with any form of internal or external congenital anomaly or defect i.e. any condition(s) which is present since birth,
and which is abnormal with reference to form, structure or position?

Hepatitis B Hepatitis C HIV Infection AIDS/AIDS Related Gynecological Disorder

Any Other Medical Condition

No, I have never been investigated/diagnosed or treated for any of the above conditions
4. Have you ever been hospitalised or been advised to under go any investigation (other than routine checkup) or treatment or surgery? Yes No

5. In the last 1 year, have you been absent from Work/Educational Institution due to an illness or injury for a continuous period of Yes No
more than 10 days?

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6. Tobacco/Alcohol/Drugs Consumption: (In case you consume or have ever consumed) Yes No
Proposer Life Insured
 No.
No. of
Substance Type Qty Frequency of Type Qty Frequency
Yrs.
Yrs.
Tobacco/Nicotine products (in the last 1 year
(sticks/gms))Cigarettes/Beedis/Cigars/Gutkha/Flavored
PanMasala etc.
Alcohol (ML) - Beer/Wine/Hard Liquor
Drugs other thanprescribed by Doctors -Cannabis,
Marijuana,Ecstacy, Heroin, LSD,Amphetamines or otherillegal
drugs

Declaration by Proposer and Insured,

I/We hereby declare that I/ We fully understand the meaning and scope of the Proposal form submitted by me through the website of the Company
www.maxlifeinsurance.com and the questions contained above and am submitting the completed proposal of my/ our volition, and confirm that I / We have not been
induced by anyone to make the proposal. I / We have understood the nature of the questions and the importance of disclosing all material information. I / We further
declare that the statements and declarations herein shall be the basis of the Policy between me / us and the Company and that I/ We have made complete, true and
accurate disclosure of all the facts and circumstances as may be relevant, and have not withheld any information that may be relevant to enable the Company to make
an informed decision about acceptability of the proposal. In case of fraud or misrepresentation, the company reserves the right to cancel the policy, subject to fraud or
misrepresentation being established by the insurer in accordance with section 45 of the Insurance Act, 1938 as amended from time to time.

I / We undertake to notify the Company, forthwith in writing, of any change in any of the statements made in the proposal subsequent to the signing of thisproposal and
acceptance of risk and issuance of the Policy by the Company.

I / We also confirm if any future premium or other payment due to the Company is made by me / us either Personally or though the website or through standing
instruction or any other permitted mode then the Company shall not be liable unless the amounts are received and realized by the Company within the time the
Company stipulates for receipt of the payments and the Company decides to underwrite the risk. The First Premium and subsequent premiums will be paid out by
legally acquired sources of income. In case the premium is paid out of any account other than my own, I shall ensure that such payment is permitted under the Section
80C/ 80D of the Income Tax Act, 1961. I will provide information as and when required by the Company, acting on its own or under any order or instructions received
from the Statutory Authorities, as regards to the sources of funds or utilizations or withdrawals. I agree that the Company may provide any information related to me as
available to the Company at any time, to any Statutory Authority in relation to the laws governing prevention of money laundering, applicable in the country.

I/We hereby authorize the Company to conduct screening/confirmation/reconfirmation of my /our health status through medical examinations 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 purpose and not confirmatory of HIV/AIDS. Based on the results of these tests,
the Company reserves the right to accept, decline or offer alternate terms on my proposal for life insurance.

To enable the Company to assess the risk under my/our proposal or for any other purpose in relation to the policy, I/We , my/our heirs,administrators or executors or
assignees hereby authorize my past and present employer(s)/business association/ medical practitioners/Other agencies to disclose and make available to the
Company such details/records as may be requested for by the Company.

I understand that by submitting the proposal form through the Company website. I will be bound by such statement / disclosure / non disclosure of material facts in the
same manner and to the same extent as if I have signed and submitted a written proposal for insurance to the Company. I further agree and confirm that any
communication done between myself or the Company through the email or any other electronic mode shall be binding upon me, in the same manner as if, I have signed
and / or accepted in writing including submission of documents such as ID proof, resident proof and income proof.

"I understand that I have disclosed my personal information with Max Life and I hereby provide my consent to Max Life Insurance to share my information with its
authorized service providers for servicing this policy/ proposal such as issuance, renewal, claims process with respect to this policy as per the regulation applicable from
time to time".
I Agree to the terms and condition & confirm that I am paying through my Debit Card/Credit Card/Internet Banking Account.I/we agree to receive regular
reminders/alerts regarding this policy/proposal.

Proposer Name
Insured Name
Mr. Sridhar P

Date: 11/04/2019 Date:

Agent Advisor/Specified Person Code: 481310 SP Certificate:
Phone No. with STD Code:
Date:

Important Notes: 1. A Receipt of the Completed Proposal and initial payment does not create any obligations upon the Company to underwrite the risk. The
Company shall not be liable until it has underwritten the risk and issued the Policy.

2. Section 45: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of issuance of policy, from
the date of the Commencement of Risk or Revival of the policy or the date of the rider to the policy, whichever is later. However, Insurer may question the Policy at
any time within three years from the date of issuance of policy, from the date of Commencement of Risk or Revival of the policy or the date of the rider to the policy,
whichever is later, on the ground of fraud, in which case insurer shall inform Proposer/Life Insured/legal representatives in writing specifying the grounds and materials
on which such decision is based. For other details please refer to Section 45 of the Insurance Act, 1938 as amended from time to time..

3. Section 41: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continue an insurance
inrespect 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: Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by
himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if at the time of such acceptance the
insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer. (2) Any person making default in
complying with the provisions of this section shall be punishable with fine which may extend to ten lakhs rupees.

4. Free Look period: If you are not satisfied, you may opt to cancel the Policy by returning the original Policy to the Company with a written request within 30(Thirty)
days from the date of receipt of the Policy. Upon return, the policy will terminate forthwith and all rights, benefits and interests under the Policy will cease immediately.
We will only refund the premiums received by us, after deducting the proportionate risk premium for the period of cover, charges of stamp duty paid and expenses
incurred on medical examination of the Life Insured, if any.
5. Section 39: In case nomination facility is availed, section 39 of the Insurance Act, 1938 as amended from time to time shall apply.

4 OnlineTerm / 1109 / Ver 1.1

 CKYC Annexure
1. CENTRAL KYC REGISTRY | Know Your Customer(KYC) Application Form | Individual
NEW
Application Type:

KYC Number:

2. PERSONAL DETAILS (Please refer instruction A at the end)

Prefix First Name Middle Name Last Name

Mr Ms Dr Mrs Sridhar P
Name(Same as ID proof)

Ms.
Maidan Name(If any)

Palanisamy
Father/ Spouse Name

Ms.Eswari P
Mother Name

24/11/1993
Date of Birth*

Male Female
Gender

Single Married Divorced Widow

Marital Status

Indian NRI
Nationality

Indian NRI
Resident Status

Salaried Professional Self Employed from Home Self-employed Housewife Retired Student Others
Occupation Type

3.RESIDENCE FOR TAX PURPOSESIN JURISDICTION(S) OUTSIDE INDIA

Tax Identification number or Equivalent

Country Code of Jurisdiction of Residence

India
Place/City of Birth* Country Code of Birth

4. PROOF OF IDENTITY(Please refer instruction C at the end)

PAN card
ID proof name

ENLPS2570F
ID proof Number

ID Expiry date

5. PROOF OF ADDRESS(PoA)*
Address proof name

SO Palanisamy
Address Line1

No 81, Raja Street

Address Line2

Perundurai
Address Line3

Erode
City

TAMIL NADU
State

638002
PIN

INDIA
Country

6. Address in the Jurisdiction details where Applicant is Resident Outside India for Tax Purposes
Overseas Address
7. Contact Details
9688889911
Mobile Number

p.sridhar.pri@gmail.com
Email -ID

8. APPLICATION DECLARATION

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any change
therein immediately. In case of the above information is found to be false or untrue or misleading or misrepresenting. I am aware that I am be held liable
 for it.

I hereby consent to receiving information from Canral KYC Registry through SMS/Email on the above registered number/email address

Name/Date/Place
Mr. Sridhar P
Name of the applicant

Erode
Place

10/04/2019
Date

5 OnlineTerm / 1109 / Ver 1.1