Duplicate

21-Mar-2012

MR. ANIL KUMAR

97/6
JASWANT WALI GALI
NEAR TRANSF,KURENI NARELA NORTH WEST
NEW DELHI 110040
DELHI
G.O. Name : ADL21
Policy No. : 864791496
Telephone : 9811032288, --
Email ID : A.R.ANILROHILLA78@GMAIL.COM

Dear MR. ANIL KUMAR,

Thank you for choosing Max New York Life as your preferred life insurance partner.

I welcome you to the rapidly expanding and satisfied family of Max New York Life policy holders. We are commited to
offering you world-class life insurance solutions backed by the highest standards of customer service. In the last ten
years, Max New York Life has substantial achievements to its credit:
■ Solid foundation : Rs 2126 crores capital invested

■ National Presence: 466 own offices in 389 cities and sales in over 500 cities through distribution channels
■ Large customer base : More than 5.9 million policies issued
■ Substantial life cover : Sum assured (Insurance cover to policy holders) of more than Rs 1,52,348 crore
■ Quality certification : The first ISO certified life insurance company in India
Please go through the enclosed policy, which explains all the features, benefits and terms of your Max New York Life
Policy, in as simple a manner as possible. In the unlikely event of your not being completely satisfied with the policy,
you have the option to cancel it by returning the original policy with a written request to us, within 15 (fifteen) days
from date of receipt. In such a case, the premiums paid will be refunded to you without interest, less proportionate risk
premium for the period of cover and any medical fees and expenses that we may have incurred on stamp duty

To make it easy and convenient for you, we have in place 5 different ways to get in touch with us :

1. Through your Agent Advisor

2. Call our Customer Helpline number 1800 200 5577 (Tollfree from MTNL or BSNL network).
3. Email us at service.helpdesk@maxnewyorklife.com
4. Use our website www.maxnewyorklife.com
5. Visit our office in your location.

We will be delighted to offer any assistance or clarification you may require about your life insurance policy.
We look forward to being your partner for life.

Yours Sincerely,

Rajesh Sud
Managing Director & CEO

AGENT NAME: MRS. VEENA TUTEJA (208331), PH.NO.: 9211609570,

9213918969, ADDRESS:Plot No.- 4, Khasra No.- 514, Ground Floor,
Block- G, Near Budho Devi Hospital, Punjabi Colony, Narela, New
Delhi 110040 (N/A)
NB13
Max New York Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800 200 5577
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxnewyorklife.com E-mail: service.helpdesk@maxnewyorklife.com
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 Policy Document
Life Pay Money Back
(Participating Plan)
UIN-104N022V01
Max New York Life Insurance Company Limited
Regd. Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi -110 020

Max New York Life Insurance Company Limited (the ``Company'') has entered into this contract of
insurance (the ``Policy'') on the basis of the Proposal together with the premium deposit and declarations
and evidences received from the Proposer for effecting a life insurance contract on the life of the person (the
``Life Insured'') named in the schedule hereto (the``Schedule''). This Policy is subject to the terms and
conditions stated herein and the Schedule.

The Company agrees to pay the Benefits under this Policy on the happening of the Insured Event, while
this Policy is in force.

Signed by and on behalf of

Max New York Life Insurance Company Limited

AnaljitSingh
Chairman

Date Of Policy : 20-Mar-2012

NB79
Max New York Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800 200 5577
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxnewyorklife.com E-mail: service.helpdesk@maxnewyorklife.com
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 THE SCHEDULE PAGE
BASE POLICY - Life Pay Money Back
TYPE OF POLICY - Participating GENERAL OFFICE - MNYL Agency Distribution Delhi 21

POLICY NO: 864791496 PROPOSAL NO : 864791496

CLIENT ID : 0000372894 DATE OF PROPOSAL: 29-Feb-2012

POLICY HOLDER : GENDER : Male

MR. ANIL KUMAR
ADDRESS : PAN NO. : ARYPK6004B
97/6
JASWANT WALI GALI NEAR TRANSF,KURENI NARELA
NORTH WEST
NEW DELHI 110040
DELHI

LIFE INSURED : GENDER : Male

MR. ANIL KUMAR
DATE OF BIRTH OF LIFE INSURED :
05-Feb-1977
ADDRESS :
97/6
JASWANT WALI GALI NEAR TRANSF,KURENI NARELA NORTH WEST
NEW DELHI 110040
DELHI
NOMINEE (S) APPOINTEE (In case Nominee is a minor)
MRS.ADESH .

EFFECTIVE DATE OF COVERAGE : 29-Feb-2012

PREMIUM MODE : Annual

PREMIUM METHOD : Direct Bill BILLED DRAW DATE : NA

AGENT'S DETAILS
NAME : MRS. VEENA TUTEJA CODE : 208331
ADDRESS : MOBILE/ LANDLINE NUMBER : 9211609570, 9213918969
Plot No.- 4, Khasra No.- 514, Ground Floor, Block- G, Near Budho Devi Hospital, Punjabi Colony, Narela
New Delhi 110040 (N/A)

LIST DURATION INSURED SUM MODAL DUE DATES ANNEXURE MODAL

OF OF EVENT INSURED PREMIUM WHEN REFERENCE FLAT EXTRA
COVERAGES COVERAGE (`) (`) PREMIUM PREMIUM*
PAYABLE; (`)
DATE WHEN
LAST
INSTALLMENT
OF PREMIUM
DUE
BASE POLICY
Money Back 16 Years; 29- Maturity/ 200000 17572 29th of Feb NA NA
FEB-2028 Death of the Every Year;
Life Insured 28-Feb-2027
RIDER(S)
Personal Accident Renewable As stated in 200000 270 29th of Feb ADB NA
Benefit Every Year till Annexure Every Year;
60th birthday 28-Feb-2027
of Life insured
TOTAL SERVICE TAX FOR ALL COVERAGES UNDER BASE POLICY AND RIDER(S) : `299.3
TOTAL MODAL PREMIUM FOR ALL COVERAGES UNDER BASE POLICY AND RIDER(S) : `18141.30
THE BENEFITS ARE PAYABLE TO :
The Policy Holder or his assignees or nominees or legal heirs or proving executors or administrators or other legal
representatives who shall take out representation to his estate from a competent court.
SPECIAL PROVISIONS :

3 of 20
DEFINITIONS insured of paid up additions, in any.
In this Policy, you; your; refers to the life insured if he is also the Policy Holder or (2) Death Benefit
the Policy Holder if he is not the life insured, we; us; our; ours; ''the Company''
refers to Max New York Life Insurance Company Limited. I) On the death of the Life Insured
''Age'' shall mean the age of the Life Insured attained on the last birthday on or On the death of the Life Insured, we shall pay the following Benefits
prior to the Effective Date of Coverage specified in the Schedule. under this policy:
''Effective Date of Coverage'' shall mean the date shown in the Schedule on
which the coverage of risk under your Policy commenced. i) On death of the Life Insured after attaining ten (10) years of age
''Policy Holder'' shall mean the person who owns the Policy. but before maturity we shall pay Sum Insured together with sum
''Life Insured'' shall mean the person on whose life the policy is being effected. insured of paid up additions, if any.
PREMIUM PROVISIONS
ii) On death of Life Insured before attaining ten (10) years of age
Payment of Premium we shall pay the premiums received by us together with interest
Premiums are payable to us on the due dates specified in the Schedule. The at the rate of three (3) percent per annum, compounded annually,
Premium Mode can be changed subsequently, upon our receipt of your written subject to a maximum payment not exceeding the Sum Insured.
request. However such change shall become effective only on the next Policy
anniversary date immediately following the receipt of such request. Change Living Benefit already paid during the lifetime of the Life Insured
sought in the Premium Mode will lead to a revision in the Modal Premium amount. shall not be deducted from the benefit payable on death of the
Grace Period Life Insured.
We allow a grace period of thirty days from the due date for payment of each
Premium. In case premium mode is monthly, the grace period shall be fifteen II) On death of the Policy Holder (where Policy Holder and Life
days only. During the grace period we will accept the premium without interest. Insured are differentpersons)
The insurance coverage continues during this grace period but if the Life Insured Where the Policy Holder has purchased the policy on the life of
dies during the grace period, the Company shall be entitled to deduct the unpaid spouse and the policy has not been assigned, then on death of Policy
Premium from the Benefits payable under the Policy. Holder, the Life Insured shall have the option to continue the Policy by
Non-payment of Premium payment of premiums.
If a Premium is not received by us by the end of the Grace Period, the Policy will
Where the Policy Holder has purchased the Policy on the life of his/ her
lapse. If the Policy has cash value then, from the due date of payment of Premium
minor child, then on death of the Policy Holder, we may allow the
it will be subject to Non Forfeiture Provision, elected by you in the Proposal Form
surviving parent to continue the policy by payment of premiums. All
or as per your subsequent request, in writing. All insurance cover will end at the
benefits or proceeds payable under such a Policy shall belong to the Life
time of lapse and also no living benefit is payable upon lapse of the Policy.
Insured or his Estate.
Revival of Policy
Within three years after the Policy has lapsed you may apply in writing for revival (3) Non-Forfeiture Benefits
of the Policy, if you have not surrendered it. We may upon written request from At any time after the Policy has acquired Surrender Value, you may
you, and on production of evidence of insurability acceptable to us (cost of which surrender the policy for cash or exercise any one of the following
to be borne by you), and at our discretion revive the Policy on such terms and non-forfeiture options, as opted for by you in the Proposal Form or by a
conditions as are applicable at the time of revival. All overdue Premiums must be subsequent election in writing, which must be received by us before the
paid together with interest at such rates as may be declared by us from time to due date of payment of premium.
time. The revival of the Policy shall take effect only after its revival is approved
(i) Reduced Paid Up Insurance
by us and communicated to you in writing. Upon revival the Company shall pay
Reduced Paid Up Insurance is the amount of paid up insurance, which
all benefits that would have become due and payable under the Policy had the
can be purchased by utilizing the Surrender Value.
policy not lapsed.
We do not need evidence of insurability if we receive the overdue premium This reduced paid up insurance will acquire cash value. Such paid up
together with interest within 30 days after the expiry of the grace period, but the policy is not entitled to any bonus.
insured must be living when we receive the payment.
(ii) Extended Term Insurance (ETI)
If the Policy has been surrendered and the benefits under the Policy, if any, have The Surrender Value will be used as a single Premium to buy Term
been paid by us, then the Policy cannot be revived. Insurance equal to the current Sum Insured of this Policy for a term,
The cost of providing evidence of insurability would be the actual medical which the Surrender Value can purchase. Such ETI is not eligible for
examination fee plus an administrative fee for revival of policy, which shall not be bonus or cash value. The maximum term for this ETI cannot exceed the
more than `2,000/-. The maximum administrative fee may be revised depending remaining term of this Policy. Should the Surrender Value be sufficient
upon the annual inflation rates. to buy a single premium Term Insurance for a term longer than the
BENEFITS remaining term of this Policy then such excess amount will be paid in
cash to the Policy Holder.
(1) Living Benefit
We shall pay Living Benefit as under:- BONUS
While this policy is in force it is entitled to bonus, if any, declared by the Company.
Events on the Amount payable as percentage of Sum Insured* No bonus is payable for the first two Policy years. Bonus, if any, is payable
happening of which Where duration Where duration Where duration on the Policy anniversary, from the surplus arising from the actuarial valuation
the Living Benefit of the participating life insurance fund, if all premiums due before then have
of coverage of coverage of coverage
will be paid been paid. Notwithstanding anything to the contrary, Bonuses are always
is 16 years is 20 years is 24 years
non-guaranteed.
The bonus will be applied as per one of the following options selected by you
Life Insured surviving 10% 10% 10% in the Proposal Form:-
4 years from effective Paid in Cash -The Bonus declared will be paid to the Policy Holder in
date 1)
cash.
Life Insured surviving 20% 15% 10%
8 years from effective 2) Premium Offset - This entitles you to offset all the premium payable by
date you under the Policy against the bonuses, if any. In the event the bonus
is in excess of the premium payable under the policy, the excess will be
Life Insured surviving 30% 20% 15% paid to you in cash. However, if the bonus is not sufficient, the shortfall,
12 years from should be paid in full before this option can be exercised.
effective date
Purchase Paid Up Additions - This entitles you to utilize the bonus, if any, to
Life Insured surviving 50% 25% 15% buy single premium endowment benefits, which will mature alongwith the base
16 years from policy. In the event of death of the Life Insured prior to maturity we shall pay
effective date sum insured of single premium endowment benefits, if any.
Life Insured surviving - 40% 20% While the Policy is in force, you may make a written request to change the
20 years from bonus option. However such change shall become effective only on the Policy
effective date anniversary date which follows the policy anniversary date immediately after the
Life Insured surviving - - 40% receipt of such request.
24 years from At any time while the Policy is in force and the paid up additions have acquired
effective date Cash Value, you may surrender such paid up additions, partially or in full, subject
to a minimum surrender value of ` 5000/- and not more than once in a policy year.
*As specified in the Schedule
On Maturity, along with the last installment of the Living Benefit, we shall pay
the sum
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GENERAL PROVISIONS
The Contract
The contract consists of this policy including Schedule, attached riders and
endorsements if any, the proposal, medical evidence, any written statements,
answers, premium deposits and other declarations/particulars (if any) received
from you. No Agent is authorized to amend/ change the contract.
Full Disclosure & Incontestability
This Policy has been issued on your representation that you have made
full disclosures of all relevant facts and circumstances. Any concealment,
non-disclosure, misrepresentation or fraud by you shall render the Policy liable
for cancellation and/or be voidable at the option of the Company. In case of
fraud, the Premium(s) received will not be refunded.
We also draw your attention to Section 45 of the Insurance Act, 1938 - which
states as follows :
No policy of life insurance shall after the expiry of two years from the date on
which it was effected be called in question by an insurer on the ground that
a statement made in the proposal for insurance or in any report of a medical
officer, or referee, or friend of the insured, or in any other document leading to the
issue of the policy, was inaccurate or false, unless the insurer shows that such
statement was on a material matter or suppressed facts which it was material
to disclose and that it was fraudulently made by the policy-holder and that the
policy-holder knew at the time of making it that the statement was false or that it
suppressed facts which it was material to disclose. Provided that nothing in this
section 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.
Policy Review Period
Please examine your Policy carefully. You may opt to return the Original Policy
to the Company with a written request for cancellation of the Policy within fifteen
days from the date of receipt of this Policy. In such an event the Premiums paid
less proportionate risk premium for the period of cover, any medical fees and
expense incurred on stamp charges by the Company will be refunded without
interest. If the Policy is sent by post it shall be deemed to have been received
by you within three days of posting.
Currency and Place of Payment
This policy is denominated in Indian Rupees. All payments to or by us will be in
Indian Rupees at any of our offices in India.
Governing Laws and Jurisdiction
This Policy shall be governed by and is subject to the laws of the Republic
of India. The Parties shall be subject to the exclusive jurisdiction of the courts
in India for all matters and disputes arising from, relating to or concerning the
Contract.
Travel, Residence and Occupation
This Policy contains no restrictions as to travel, residence or occupation except
as otherwise provided in any Special Provisions to this Policy or by law.
Misstatement of Age or Gender
All Premiums are calculated based on the Age and Gender of the Life Insured
as declared in the Proposal. Without prejudice to the full disclosure and
incontestability provisions, the Company may in its sole discretion:
i) in case the age at the time of issuance of Policy is lower or higher than
the age declared or gender is mis-stated, adjust the premium and/or
benefits payable had the true age or gender been stated at issue and
the policy would have been issued based on our underwriting rules at
that time, and
ii) in case the Life Insured's true age at the time of issuing the Policy is
higher than the maximum issue age limit under the Policy, cancel the
Policy and forfeit Premium(s) received.
Vesting on attaining majority
If Life Insured is a minor, the Policy shall automatically vest in Life Insured on
his attaining majority (eighteen years) and upon such vesting the Policy shall be
deemed to be a contract between the Company and the Life Insured, who shall
be regarded as the Policyholder and the Company shall deal directly with him.
Any assignment or nomination of the Policy contrary to this provision would be
null and void against the Company.
Cash Value
This Policy will acquire cash value if it has been in force for at least three years
and provided all the Premiums that have fallen due have been received. The
guaranteed cash value in this Policy will be thirty (30) percent of the Premium(s)
(excluding the first year's Premium) received less all the living benefits already
paid.
Surrender Value
After the Policy has acquired Cash Value, you may opt to surrender this
Policy. The Surrender Value payable will be subject to the condition that the
Policy is in full force and that there are no statutory or other restrictions to the
contrary. The Surrender Value payable will be equal to Cash Value accrued to
the date of surrender.
Nomination and Assignment
Where the Policy Holder is Life Insured, the person named by the Policy Holder
in the proposal form as the nominee/s, shall be the person to whom the benefit
under the Policy will be paid in the event of death of the Life Insured. Such
nomination only indicates the person, who is authorized to receive the amount
on the payment of which we will receive a valid discharge of our liability under
the Policy. Change in nomination, if any, may be made by the Policy Holder at
any time during the term of the Policy and must be registered with us.
You may also assign the benefits under the Policy in favour of the person
named by you whereby the beneficial interest, right and title under the Policy
get transferred to such person. If the Policy has been issued on the life of a
minor, any assignment done by the Policy Holder prior to life insured reaching
the age of 18 (eighteen) years, shall upon the life insured reaching the age of 18
(eighteen) years stand automatically cancelled and the policy shall automatically
vest with life insured and not the Assignee. You can assign the entire Policy with
Riders, if any, and not individual riders and base policy separately. An absolute
assignment shall automatically cancel a nomination except any assignment in
favour of the Company. Notice of assignment (including any change thereof),
should be submitted for registration to the Company.
In registering an assignment or nomination, the Company does not accept any
responsibility or express any opinion as to its validity or legality.
Suicide Exclusion
Notwithstanding anything stated in the Policy, if the Life Insured under the Policy
dies by suicide, whether sane or insane, within one year from the Date of Policy
or the Effective Date of any revival of this Policy, the Policy Coverage shall come
to an end simultaneously. In such an event, we will only refund the Premium(s)
received from the Date of Policy or the effective date of any revival , whichever
is later, without interest, less any expenses incurred by us.
Claims
Subject to full disclosure and incontestability provision stated above and the
Policy remaining in full force and we have satisfactory proof of death
of the Life Insured, its cause, Claimant's Statement, Original Policy, Death
Certificate, Attending Physician's statement, Hospital Treatment Certificate,
Burial/Cremation Statement, Employer's Certificate, F.I.R / Postmortem report
(wherever applicable), Photo-identity proof of the Claimant, documents
establishing right of the Claimant and such other documents required by the
Company at that time, we will settle the claim.
Dispute Redressal Cell
1. All consumer grievances may be first addressed to the Company's Customer
Complaint Resolution Unit at 90A,Sector 18, Gurgaon, 122002, Haryana,
India or the servicing General Office as mentioned in the Schedule or write
to us at service.helpdesk@maxnewyorklife.com.
2. In case the Policyholder is not satisfied with the decision of the above office,
or has not received any response within 2 weeks, he may contact by way of
a written complaint signed by him or by his legal heirs with full details of the
complaint and his contact information, to the following official for resolution:
Head Operation and Delivery
Max New York Life Insurance Co. Ltd
Plot No. 90A, Sector 18
Gurgaon, 122002, Haryana, India
Toll free - 1800 200 5577
Email - Manager.Services@maxnewyorklife.com
3. In case the Policyholder is not satisfied with the decision/resolution of
the Company or has not received any reply within a period of Thirty (30)
days from the Company, the Policyholder may approach the insurance
ombudsman, at the address mentioned in Appendix A, if the grievance
pertains to:
(i) any partial or total repudiation of claims by the Company;
(ii) Any dispute on the legal construction of the Policy in so far as such
disputes relate to claims;
(iii) Delay in settlement of claim;
(iv) Any dispute with regard to Premium paid or payable in terms of the
Policy; or
(v) Non-issue of any insurance document after receipt of Premium.
You can obtain address of the insurance ombudsman from Our Office or from
the IRDA website address www.irdaindia.org. The List of Ombudsman is also
attached as Appendix A.
4. As per provision 13(3) of the Redressal of Public Grievances Rules 1998, the
complaint to the insurance ombudsman can be made within a period of one
year after the insurer has rejected the representation or sent his final reply
on the representation of the complainant, provided the complaint is not on
the same matter, for which any proceedings before any court, or consumer
forum or arbitrator is pending.
Notices
All communications relating to this policy may be addressed to: Max New York
Life Insurance Company Limited, DLF Square, 11th floor, Jacaranda Marg, DLF
City, Phase II, Gurgaon -122 002, Haryana.
Taxes
All premiums and benefits are subject to applicable taxes and levies including
service tax, which shall be borne by the Policyholder. The Company shall be
entitled to collect such applicable taxes and levies from the policyholder as
per prescribed procedure.
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ENDORSEMENT

Total stamp value : `50

6 of 20
 APPENDIX A: List of Ombudsman

NAME OF THE OMBUDSMAN

Office of the Ombudsman Areas of Jurisdiction
AND Contact Details
AHMEDABAD Shri P. Ramamoorthy
2nd Floor, Ambica House,Nr. C.U. Shah Tel.:- 079-27546840 Gujarat, UT of Dadra & Nagar
College,Ashram Road,AHMEDABAD-380 014. Fax : 079-27546142 Haveli, Daman and Diu
Email ins.omb@rediffmail.com
BHOPAL
Janak Vihar Complex,2nd Floor, 6, Tel.:- 0755-2569201 Madhya Pradesh &
Malviya Nagar,Opp. Airtel, Near New Fax : 0755-2769203 Chhattisgarh
Market,BHOPAL(M.P.)-462 023. Email bimalokpalbhopal@airtelmail.in
BHUBANESWAR Shri B. P. Parija
62, Forest Park,BHUBANESHWAR-751 009. Tel.:- 0674-2596455 Orissa
Fax : 0674-2596429
Email ioobbsr@dataone.in
CHANDIGARH
S.C.O. No.101-103,2nd Floor, Batra Tel.:- 0172-2706468 Punjab, Haryana, Himachal
Building.Sector 17-D,CHANDIGARH-160 017. Fax : 0172-2708274 Pradesh, Jammu & Kashmir,
Email ombchd@yahoo.co.in UT of Chandigarh
CHENNAI Shri V. Ramasaamy
Shri V. Ramasaamy,Fathima Akhtar Tel.:- 044-24333668 /5284 Tamil Nadu, UT-Pondicherry
Court,4th Floor, 453 (old 312),Anna Fax : 044-24333664 Town and Karaikal (which are
Salai,Teynampet,CHENNAI-600 018. Email insombud@md4.vsnl.net.in part of UT of Pondicherry)
NEW DELHI Shri Surendra Pal Singh
Shri Surendra Pal Singh,2/2 A, Universal Tel.:- 011-23239633 Delhi & Rajashthan
Insurance Bldg.,Asaf Ali Road,NEW Fax : 011-23230858
DELHI-110 002. Email iobdelraj@rediffmail.com
GUWAHATI Shri D. C. Choudhury
Shri D.C. Choudhury,"Jeevan Nivesh", 5th Tel.:- 0361-2132204/5 Assam, Meghalaya, Manipur,
Floor, Fax : 0361-2732937 Mizoram,Arunachal Pradesh,
Near Panbazar Overbridge, S.S. Email ombudsmanghy@rediffmail.com Nagaland and Tripura
Road,GUWAHATI-781 001 (ASSAM).
HYDERABAD Shri K. Chandrahas
Shri K Chandrahas, 6-2-46, 1st Tel : 040-65504123 Andhra Pradesh, Karnataka
Floor, Moin Court, A.C. Guards, Fax: 040-23376599 and UT of Yanam -a part of the
Lakdi-Ka-Pool,HYDERABAD-500 004. Email insombudhyd@gmail.com UT of Pondicherry
KOCHI Shri R. Jyothindranathan
2nd Floor, CC 27/2603, Pulinat Tel : 0484-2358759 Kerala, UT of (a) Lakshadweep,
Bldg.,Opp. Cochin Shipyard, M.G. Fax : 0484-2359336 (b) Mahe - a part of UT of
Road,ERNAKULAM-682 015. Email iokochi@asianetindia.com Pondicherry
KOLKATA Ms. Manika Datta
Ms. Manika Datta, North British Bldg., 29, N.S. Tel : 033-22134866 West Bengal, Bihar, Jharkhand
Road, 4th Floor, KOLKATA-700 001. Fax : 033-22134868 and UT of Andeman & Nicobar
Email iombkol@vsnl.net Islands, Sikkim
LUCKNOW Shri G. B. Pande
Jeevan Bhawan, Phase-2, 6th Floor, Nawal Tel : 0522 -2231331 Uttar Pradesh and Uttaranchal
Kishore Road, Hazaratganj, LUCKNOW-226 Fax : 0522-2231310
001. Email insombudsman@rediffmail.com

MUMBAI Shri S. Viswanathan

Shri S Viswanathan, 3rd Floor, Jeevan Tel : 022-26106928 Maharashtra, Goa
Seva Annexe, S.V. Road, Santacruz(W), Fax : 022-26106052
MUMBAI-400 054. Email ombudsmanmumbai@gmail.com

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 MAX NEW YORK LIFE INSURANCE COMPANY LIMITED
Regd. Office : Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110 020
PERSONAL ACCIDENT BENEFIT RIDER
1. THE CONTRACT
1.1 This Rider Contract (''Rider'') forms part of and
supplements the Base Policy referred to in the
Schedule/ Endorsement (the ''Base Policy''). The
Proposal and other particulars (if any) together with
the premium deposit and declarations, received from
the Proposer, form the basis of this Rider. In addition
to the terms and conditions mentioned hereunder,
this Rider is also subject to the terms and conditions
of the Base Policy. In the event of any inconsistency
between the terms and conditions of the Base Policy
and this Rider, the provisions of this Rider shall
prevail with respect to the matters dealt with in this
Rider.
1.2 The Company agrees to provide the benefits under
this Rider while this Rider is in force.
2. BENEFITS
2.1 Accident Death Benefit - While the Base Policy
is in force, if the Life Insured dies by Accident,
the Company shall pay the benefits specified in the
Schedule/ Endorsement.
2.2 Total and Permanent Disability Benefit - While
the Base Policy is in force, if the Life Insured
meets with an Accident which results in Total and
Permanent Disability within 180 days of the accident,
the company shall pay the benefits as specified in the
Schedule/Endorsement.
2.3 The benefits under this Rider are in addition to the
benefits available under the Base Policy.
3. PERIOD OF COVERAGE
The Rider will be effective on and from the Effective
Date of this Rider and shall remain valid for the
period stated in the Schedule/ Endorsement unless
terminated in accordance with Section 8 (eight)
below.
4. DEFINITIONS
4.1 Death by Accident means
death is caused by violent, accidental, external and
visible means as revealed by an autopsy provided
such death was caused directly by such accident,
and independently of any physical or mental illness
within 180 days of the date of accident; and
NB71
Max New York Life Insurance Co. Ltd
11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Phone 2561700 Fax 2389268 (From Delhi and Other cities: 0124) Customer Helpline: 1800 200 5577
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxnewyorklife.com E-mail: service.helpdesk@maxnewyorklife.com
4.2 Total and Permanent Disability
means accidental injuries which, within 180
days from the happening of such accident and
independently of all other causes, results in :
(a) irrecoverable loss of entire sight in both eyes; or
(b) amputation or loss of use, of both hands at or
above the wrists; or
(c) amputation or loss of use, of both feet at or
above the ankles; or
(d) amputation or loss of use, of one hand at or
above the wrist and one foot at or above the
ankle,
such that the Life Insured becomes incapable of
engaging in any gainful activity or carrying out any
work, occupation, or profession to earn or obtain any
wages, compensation, remuneration or profit.
5. EXCLUSIONS
Notwithstanding anything to the contrary stated
herein, no Benefits under this Rider will be payable if
Death by Accident or Total and Permanent Disability
occurs from, or is caused by, either directly or
indirectly, voluntarily or involuntarily, one of the
following:
5.1 suicide or attempted suicide or intentional
self-inflicted injury, by the Life Insured, whether
sane or not at the time;
5.2 Life Insured being under the influence
of drugs, alcohol, narcotics or psychotropic
substance, not prescribed by a Registered
Medical Practitioner;
5.3 Injuries resluting from war (declared or
undeclared), invasion, civil war, riots, revolution
or any warlike operations;
participation by the Life Insured in a criminal or
5.4
unlawful act;
5.5 service in the military/ para-military, naval, air
forces or Police organizations of any country in
a state of war (declared or undeclared) or of
armed conflict;
5.6 participation by the Life Insured in any flying
activity other than as a bonafide passenger
(whether paying or not), in a licensed aircraft
provided that the Life Insured does not, at that
time, have any duty on board such aircraft;
5.7 engaging in or taking part in professional
sport(s) or any hazardous pursuits, including but
not limited to, diving or riding or any kind of
race; underwater activities involving the use of
breathing apparatus or not; martial arts; hunting;
mountaineering; parachuting; bungy-jumping;
5.8 the radioactive, explosive or hazardous
nature of nuclear fuel materials or property
contaminated by nuclear fuel materials or
accident arising from such nature.
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 The above exclusions shall be in addition to the any liability, except that the Company will refund such
exclusions provided under the Base Policy. Premium(s), without interest.
6. CHANGE OF OCCUPATION ETC. 9. NOTICE AND ADMISSION OF CLAIM
The Policy Holder is required to inform the Company The Company must be notified in writing within ninety
of any change in the occupation, profession, or (90) days from the date of Death by Accident or Total
hobbies of the Life Insured, occurring during the term and Permanent Disability of the Life Insured. Failure
of this Rider, failing which the Company may decline to do so will invalidate a claim. Admission of any
the Benefits in case the Insured Event arises out claim will be subject to production of such proof as
of such changed occupation, profession or hobbies. the Company may reasonably require being given
In the event of such a change the Company, in within sixty (60) days from the date of claim.
its absolute and sole discretion, reserves the right 10. ASSIGNMENT
to take such action as it may deem appropriate This Rider or the benefits under this Rider cannot
including right to cancel the rider. be assigned by the Policy Holder separately from
7. PREMIUM & RENEWAL the Base Policy. If the Base Policy is assigned by
In Case this Rider is attached to a Traditional the Policy Holder, this Rider and the benefits under
7.1 the Rider shall also be assigned along with the Base
Plan:
This Rider can be renewed on every Base Policy Policy.
anniversary, at such rates and on such terms and 11. REINSTATEMENT OF THE RIDER
conditions as may be determined by the Company at At any time after the Rider has ceased to be valid
the time of such renewal. the Policy Holder may request for reinstatement of
In case this Rider is attached to a Unit Linked the Rider. Upon such request, the Company may
7.2
Plan: at its sole discretion, reinstate the Rider, subject
a) The premium received by the Company under to reinstatement terms as may be in force at the
this Rider shall be invested in the Funds relevant time.
selected by the Policy Holder and allocated to
the Unit Account
b) Each month an appropriate number of Units,
including a pat thereof, in the Unit Account will
be
cancelled at their Bid Price to meet the charges
under this Rider. We reverse the right to review
the charges.
c) The Rider can be renewed on every Base Policy
anniversary at such rates and on such terms and
conditions as may be determined by the
Company at the time of such renewal.
8. TERMINATION
This Rider shall automatically terminate :
8.1 if the Base Policy goes into Non-Forfeiture
(applicable only in case of a Traditional Plan),
or has matured, expired or lapsed or has been
paid-up, surrendered, cancelled or terminated
for whatever reason; or
Upon payment of Benefit specified under
8.2
Section 2.1 or Section 2.2
8.3 on the death of the Life Insured; or
8.4 on the anniversary of the Base Policy at which
the Life Insured is of age sixty (60); or
8.5 upon the Policy Holder's written request for
cancellation of the Rider
Termination of this Rider shall be without prejudice
to any rights and liabilities which has or have
arisen prior to such termination. Any payment or
receipt, of any Premium(s) hereunder subsequent to
cancellation/ termination of this Rider shall not create

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13 of 20
 Life Pay Money Back
UIN- 104N022V01
Participating
Policy/Proposal No:[ _________________ ]
Date of Illustration - Mar 21, 2012 6:53:10 PM

Insured ANIL KUMAR 864791496

Age at inception of Policy 35

Sex Male

Class Standard

Face Amount Rs 2,00,000

Bonus Option Paid Up Additions

Payment Mode Annual Billed

Payment Period 16 Years

PREMIUM SUMMARY

Basic Premium Rs 17,572.00 Annual - Billed

Personal Accident Benefit (UIN NO: 104C007V02) - Rs 2,00,000.00 Rs 270.00 Annual - Billed -Rating 1.00

TOTAL Rs 17,842.00 Annual - Billed

Service Tax on base premium and all rider premiums. Rs 299.30 Annual - Billed

Total Premium (inclusive of Service Tax) Rs 18,141.30 Annual - Billed

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Signature of Agent/Specified Person/Principal officer:___________________________________________ Policy Holders Signature:___________________________________________

MAX NEW YORK LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002

Page 1 of 3
 YEARLY DETAIL
The following ledger provides year by year illustrative figures for premiums required, for the policy that you have chosen.

General Details Guaranteed Non Guaranteed Rate (6% p.a.) Non Guaranteed Rate (10% p.a.)

Year Age Annual Death Cash Money Net Death Annual CV of Total Net Death Annual CV of Total
Premium Benefit Value Back Outlay Benefit Bonus Adds Cash Outlay Benefit Bonus Adds Cash
Value Value

( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs ) ( Rs )
(BOY) (EOY) (EOY) (BOY) (EOY) (EOY) (EOY) (BOY) (EOY) (EOY) (EOY)

1 35 17,842 2,00,000 0 0 17,842 2,00,000 0 0 0 17,842 2,00,000 0 0 0

2 36 17,842 2,00,000 0 0 17,842 2,00,000 0 0 0 17,842 2,00,000 0 0 0

3 37 17,842 2,00,000 32,974 0 17,842 2,00,000 4,290 0 32,974 17,842 2,00,000 6,434 0 32,974

4 38 17,842 2,00,000 25,768 20,000 17,842 2,06,660 2,945 4,436 30,204 17,842 2,09,988 4,599 6,653 32,421

5 39 17,842 2,00,000 37,952 0 -2,158 2,11,081 2,705 7,633 45,585 -2,158 2,16,892 4,376 11,636 49,588

6 40 17,842 2,00,000 51,110 0 17,842 2,15,008 3,457 10,691 61,801 17,842 2,23,245 5,642 16,559 67,669

7 41 17,842 2,00,000 65,320 0 17,842 2,19,861 4,211 14,632 79,952 17,842 2,31,165 6,956 22,960 88,280

8 42 17,842 2,00,000 40,682 40,000 17,842 2,25,577 4,968 19,488 60,170 17,842 2,40,607 8,319 30,940 71,622

9 43 17,842 2,00,000 53,990 0 -22,158 2,32,097 3,744 25,294 79,284 -22,158 2,51,526 6,758 40,605 94,595

10 44 17,842 2,00,000 68,368 0 17,842 2,36,848 4,508 30,035 98,403 17,842 2,60,102 8,155 48,989 1,17,357

11 45 17,842 2,00,000 83,908 0 17,842 2,42,379 5,272 35,731 1,19,639 17,842 2,70,107 9,604 59,110 1,43,018

12 46 17,842 2,00,000 40,710 60,000 17,842 2,48,632 6,043 42,417 83,127 17,842 2,81,497 11,115 71,082 1,11,792

13 47 17,842 2,00,000 53,860 0 -42,158 2,55,561 3,844 50,136 1,03,996 -42,158 2,94,241 8,233 85,039 1,38,899

14 48 17,842 2,00,000 68,060 0 17,842 2,59,821 4,623 55,852 1,23,912 17,842 3,03,365 9,759 96,508 1,64,568

15 49 17,842 2,00,000 83,404 0 17,842 2,64,772 5,402 62,581 1,45,985 17,842 3,13,818 11,352 1,09,969 1,93,373

16 50 17,842 2,00,000 1,00,000 1,00,000 17,842 2,70,363 6,188 70,363 1,70,363 17,842 3,25,567 13,019 1,25,567 2,25,567

Maturity Value: Rs 1,00,000 Rs 1,76,551 Rs 2,38,587

NOTES:

(BOY) Beginning of Year Value

(EOY) End of Year Value

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Signature of Agent/Specified Person/Principal officer:___________________________________________ Policy Holders Signature:___________________________________________

MAX NEW YORK LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002

Page 2 of 3
 Important Notes:

-- This is only an illustrative document. It does not purport to be a contract of insurance and does not in any way create any rights and/or obligations. Bonuses (if applicable and shown in the illustration) are not guaranteed, and bonus rates will be based on
the actual company experience from time to time. Some of the benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy offers guaranteed returns
then these will be clearly marked "guaranteed" in the illustration table on this page. If your policy offers variable returns then the illustrations on this page will show the different rates of assumed future investment returns. These assumed rates of return
are not guaranteed and they are not the upper or lower limits of what you might get back, as the value of your policy is dependent on a number of factors including future investment performance.
-- Policy benefits are payable provided all premiums are paid, when they are due. The illustrative benefits above assume that all premiums that are due will be paid on the due dates.
-- Please refer to the product brochures, for understanding the product features and explanation of the terms used in this illustration.
-- Service Tax and Education Cess would be levied as per applicable laws and would be to the account of the policyholder.
-- This plan may entitle you to certain tax benefits on your premiums as well as on your maturity value:

-- U/s 80C of the Income Tax Act 1961 on your premiums.

-- U/s 10(10D) of the Income Tax Act 1961 on your maturity proceeds of the policy.
-- U/s 80D of the Income Tax Act 1961, on your premiums towards Health insurance.
(Please note that if the premium paid in a financial year exceeds 20% of the Sum Assured, under section 10 (10D) benefit will not be available and 80C benefit will not be available for the premium exceeding 20% of the Sum Assured under the current tax
laws.)
-- The company reserves the right to revise the premium rates at portfolio level in plans for health insurance based upon the actuarial review of the claims experience subject to prior approval of IRDA and shall be communicated to you at least 30 days
prior to such change.

I ________________________________________________________ (Name), having received the information with respect to the above, have understood the above statement before entering into the contract.

Signature of Agent/Specified Person/Principal Officer: Policy Holders Signature:

Name and ID: Policy Holders Name:

Place: Date:

Date:

Company Seal:

MAX NEW YORK LIFE INSURANCE CO. LTD, 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurgaon 122 002

2010.1.2.8.6.56.54 351200000012353 10001200000001000000 100000180000 0 1

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Page 3 of 3
 INSURANCE PREMIUM RECEIPT
Policy Number: 864791496 Date: 21-Mar-2012
Name: Mr. Anil Kumar Base Life Insured: MR. ANIL KUMAR
Address: 97/6 Receipt Number: 864791496 /2011-12/01
JASWANT WALI GALI NEAR Your Agent Advisor: Mrs. Veena Tuteja
TRANSF,KURENI NARELA NORTH Agent Code 208331
WEST
Your Agent Phone No 9213918969
New Delhi - 110040
Delhi General Office MNYL Agency Distribution Delhi 21

Telephone: 9811032288, --

Dear Mr. Anil Kumar,

Thank you for choosing Max New York Life. This is to acknowledge receipt of your premium as per details below.

Should you need any further assistance, please call our Customer Help Line -1800 200 5577 (Toll free from any network). You can
also email at service.helpdesk@maxnewyorklife.com.

Yours Sincerely,
for Max New York Life Insurance Co. Ltd.

Authorized Signatory

SUMMARY OF POLICY INFORMATION

Plan Sum Insured Premium paid For Due Date Frequency Effective Date Benefit
(`) inclusive of of Coverage under
Service Income Tax
Tax # *** Act 1961,
if
applicable
Life Pay Money Back 2,00,000.00 17,843.49 29-Feb-2012 Annual 29-Feb-2012 U/s 80C
Accidental Death Benefit Rider 2,00,000.00 297.81 29-Feb-2012 Annual 29-Feb-2012 U/s 80C
Total 18,141.30

Next Premium Due on - 28-FEB-2013

Note:
# Subject to realisation of monies
*** All premiums and charges are subject to applicable taxes including service tax as per the prevailing tax laws.

Max New York Life Insurance Co. Ltd

11th Floor, DLF Square, Jacaranda Marg, DLF Phase II, Gurgaon 122 002
Customer Help Line -1800 200 5577 (Toll free from any network)
Regd Office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi 110 020, India
Visit us at: www.maxnewyorklife.com E-mail: service.helpdesk@maxnewyorklife.com
Service Tax Regn. No. 443/ST/DIV-II/GGN/02
PRM20 V1.5 24052005
E.&O.E

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 POLICY OWNER DATA

Policy Number : 864791496 Effective Date : 29-Feb-2012

Insured Name : MR. ANIL KUMAR Insured ID : 0000372894
Date of Birth : 05-Feb-1977 Age : 35
Smoker Code : Non-Smoker Sex : Male
Policy Holder : MR. ANIL KUMAR Owner ID : 0000372894
Address : 97/6 Work Ph : --
JASWANT WALI GALI Home Ph : --
NEAR TRANSF,KURENI NARELA NORTH Mobile : 9811032288
WEST
NEW DELHI 110040
DELHI

Benefit / Option Face Amount Dividend Options

Paid Left on Offset Purchase Purchase Compound

in Deposit Future Paid One year Reversionary
Cash Accumulate Premium Addition Term (%) Bonus (%)
(%) at Interest (%) (%)
(%)
Life Pay Money Back 200000 100
Accidental Death Benefit
200000 100
Rider

Service Tax Amount : ` 299.30

Annual Premium: ` 18141.30 Non Forfeiture Option: Reduced Paid Up

c.c. : 208331 MRS. VEENA TUTEJA

Work Ph 1 : 9213918969 Home Ph 1 : 9211609570
Work Ph 2 : Home Ph 2 :
Office : MNYL Agency Distribution
Delhi 21

''This document is computer generated and does not require signature''

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 864791496

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

** ACKNOWLEDGEMENT OF RECEIPT OF POLICY **

Received from Max New York Life Insurance Company Limited the following policy together with the
illustration and copy of the proposal form:

Policy Number : 864791496

Policy Holder : MR. ANIL KUMAR
Life Insured : MR. ANIL KUMAR
Email ID : A.R.ANILROHILLA78@GMAIL.COM

I hereby acknowledge receipt of the above.

___________ ___________________________
Date Policy Holder's Signature & Name

c.c. : 208331 MRS. VEENA TUTEJA

Work Ph 1 : 9213918969 Home Ph 1 : 9211609570
Work Ph 2 : Home Ph 2 :
Office : MNYL Agency Distribution Delhi 21

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