CUSTOMER SUITABILITY FORM

Ver 0.0.1

Please fill this form in BLACK INK & CAPITAL letters only.

Enter customer details

Proposer Name : F I R S T S U R N A M E

Customer Lifestage : Single Married Others Customer Income : <10 Lakhs 10 Lakhs - 25 Lakhs > 25 Lakhs

Purpose : Savings/ Business insurance Children Solution Retirement Protection/Business insurance

(We recommend that the yearly premium amount Limited Pay/

Annual premium : Mode of premium payment : Single Pay
should not exceed 40% of your annual income.) Regular Pay

Policy Term (Goal horizon) : <10 years 11 years - 20 years > 20 years (We recommend you to select the policy term to match your goal horizon)

Premium payment term : <= 10 years > 10 years (We recommend that the premium payment term should not go beyond 65 years age or your expected earning age.)

Insurance Portfolio held (Sum Assured) :

Date of Birth D D M M Y Y Y Y

Select customer risk profile*

Aggressive/Growth Balanced Conservative/Risk Averse

Equity oriented funds Balanced funds Debt oriented funds

Recommended Products as per customer's age band and risk profile.

Aggressive/Growth Balanced Conservative/Risk Averse

Life Time Classic Life Time Classic Life Time Classic
Smart Life Smart Life Smart Life
Signature Signature Signature
Pru1 Wealth Pru1 Wealth Pru1 Wealth
Smart Kid Plan (Smart Life) Guaranteed Wealth Protector Assured Savings Insurance Plan
Guaranteed Pension Plan Future Perfect Savings Suraksha
EzyGrow Smart Kid Plan (Smart Life) GIFT (Long-term)
Saral Pension Guaranteed Pension Plan Guaranteed Pension Plan
Guaranteed Pension Plan Flexi EzyGrow Sukh Samruddhi

Category - Gold EzyGrow

- Gold Pension Savings GIFT (Long-term) POS
- Easy Retirement GIFT Pro
- Saral Pension GIFT Pro POS
- Guaranteed Pension Plan Flexi Gold Pension Savings
- - Platinum
- - Saral Pension
- - Guaranteed Pension Plan Flexi
- - GPP Immediate Annuity POS
- - GIFT LP POS
- - GIFT LP
- - GIFT SP

DECLARATION (PLEASE TICK AS APPLICABLE):

I/We have understood the features of the product and believe it would be suitable for me/our insurance objective. I/We concur that I/we have availed the product after understanding the
suitability of the product(s) as per my/our needs. I/We understand that the product(s) and fund(s) recommended to me are based on the information provided by me/us and which is
considered suitable in the view and understanding of licensed intermediary and/or ICICI Prudential. I/We declare that the information provided by me for my risk profiling and
recommendation is correct and I/we will not hold licensed intermediary and/or ICICI Prudential responsible for my acceptance of product(s) and fund(s) recommended.

OR

I/We have gone through the list of product(s) and fund(s) recommended to me based on the risk profiling conducted by the licensed intermediary and/or ICICI Prudential. I/We wish to
supersede the recommendations of licensed intermediary and/or ICICI Prudential and have opted for the Life Insurance product(s) as highlighted above. I/We agree to purchase the
product(s) based on my independent assessment of the risks, merits and suitability of the product(s). I/We will not hold the licensed intermediary and/or ICICI Prudential responsible for
my acceptance of such product(s) and fund(s) as per my/our understanding.

______________________________________________ ______________________________________________
Signature of Prospect / Policyholder Signature of Agent / Intermediary / Official

Date : D D M M Y Y Y Y Date : D D M M Y Y Y Y
 APPLICATION AND CONSENT FORM

A. Proposer/Policy Owner Details (Please fill in details of Life to be Assured if same as Proposer)

First Name Middle Name Last Name

Full Name

Date of Birth D D M M Y Y Y Y Gender Male Female Transgender

Resident Status Resident NRI PIO Foreign National

B. Details of the Life to be Assured (Please fill only if Life to be Assured is different from Proposer)
First Name Middle Name Last Name
Full Name

Date of Birth D D M M Y Y Y Y Gender Male Female Transgender

Resident Status Resident NRI PIO Foreign National

Rider Rider Term/ Rider Premium

Sum Assured Modal Premium
1. Rider Rider Name Rider Option Coverage Term Payment Term
No. (in yrs) (in yrs)
(in `) (in `)
(Optional
with
Additional
Premium)

Premium payment frequency of the rider will be same as that of the base policy.

2. For Ulip-Mention Fund Name:

3. Annuity Plan Details* (Applicable only for Pension plans):

3a. Single Premium (Purchase Price): (in `) 3b. Annuity Amount to be paid (in `)

3c. Annuity Options (Please tick one option only in the appropriate box)

Product Name: Annuity Option: Deferment Period (If applicable):

3d. Frequency of Annuity payments: Yearly Half-Yearly Quarterly Monthly

DECLARATION

1. Address would be taken as per KYC Proof submitted.

2. I/We hereby confirm that
a. I am not working with in the industry of Jewellery, mining, scrap dealing.
b. I am not a Politically Exposed Persons” (PEPs).
c. I have not been or currently being investigated, charge sheeted, prosecuted or convicted or acquittal or having pending charges in respect of any criminal/civil offences in any court of law in India or
abroad. In case otherwise please specify _____________________________________________________________________________________________________________________________________________
3. I declare that I am not suffering from or have ever suffered from or have been advised to undergo regular medical consultation/investigation or treatments including hospitalization for Diabetes,
hypertension, heart, lung, kidney, liver related ailments or cancer or tumor or any kind or HIV / AIDS related ailments. If yes please specify _________________________________________________________
4. Has any of your insurance application or reinstatement application on life, accident, medical or health, critical illness, or disability ever been declined, postponed or accepted at extra premium or modified
terms? (If Yes, please provide the details) _____________________________________________________________________________________________________________________________________________
I/We confirm that (Advisor / SP / Authorized person name / Broker qualified person) ____________________________________________________________________________ has explained the relevant
documentation/ information and has also made us understand the product features and benefits. I/we confirm that I/we have answered all the questions in the form and have duly signed it after
understanding its contents. I/we declare that the information so provided is true and complete and I/we have not withheld any material information or suppressed any material facts.
I/we confirm I have seen the Benefit illustration for this application and understood the same.
In case of 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 Company reserves the right
to repudiate the claim or declare the policy void in accordance with Section 45 of the Insurance Act.
Further, I/we am/are submitting the requisite documents (Age/Address/Identity/Income Proof and photograph etc.) as applicable for further processing of this application. I/ We undertake to notify the
Company of any change in the information with respect to the life to be assured subsequent to the submitting of this form and before the acceptance of the risk by the Company. The Company reserves
the right to accept, decline or offer alternate terms on this application for life insurance.
I hereby declare and confirm that if I/We already have an existing Electronic Insurance Account then new eIA will not be created and policies will be credited into existing electronic insurance account or
eIA will be opened if not available.
I hereby declare and confirm that I am making the premium payment towards this application through my own bank account/credit card and I agree to submit a third party declaration in case the
premium payment is not made from my own account.
I/We am/are aware and agree that the Company has/may have tie-ups with various financial institutions, credit rating agencies and other third party entities to enable
sharing/collecting/validating/storing my/our KYC related documents/any other information, as shared by me/us, on confidential basis, for processing of this proposal or servicing of the resulting policy,
and may also be shared if required or permitted by any law, rule or regulation or at the request of any public or regulatory authority or if required for the purpose of preventing fraud.
I/we understand and declare that this application form is being submitted by me as an interim proposal form due to technical issues and the detailed proposal form shall be submitted by my advisor/sales
person.

Place: ___________________
______________________________ ______________________________
DD/MM/YYYY
Date: ____________________ (Signature of Life Assured) (Signature of Proposer)
(If different from Proposer)