HDFC Life Cancer Care_SATISH_H100000093770

HDFC LIFE CANCER CARE PROPOSAL FORM

* Please fill this form in BLACK INK and in CAPITAL letters with a space between words. Use separate proposal forms for each plan. Any cancellation/alteration is to
be signed by the proposer. All relevant supporting documents are to be provided. Nomination should be done. All information provided here shall be relied on and has
to be accurate, complete and true in all respects for processing the proposal quickly. In case of any doubt ,whether the particular information is material or not, please
disclose the information. In case any material information is not provided, the contract is liable to be void.

* Where the proposer has not filled up the application form or where he/she has affixed the thumb impression, the corresponding declarations are to be completed.
Pin code and Contact numbers are mandatory. Contact details mentioned herein will be used for future communication.

* The plan mentioned in this proposal form has been approved by IRDAI (Insurance Regulatory and Development Authority of India) and have been allotted a Unique
Identification Number (UIN). This number is available in our sales literature and also on IRDAI’s website for verification.

Notes: a) For any additional forms, annexes, questionnaires or drafts of declarations and affidavits, please contact your financial
consultant.

FOR OFFICE USE ONLY * Consultant Name & Code:

License No: License Expiry Date Bancassurance Code:
Company Lead: Lead Reference No: Channel Partner Customer ID:
IA/CAO Emp No**
Channel code IA/CAO Name:
Branch code: FOS code:
Tele code:

Simultaneous Proposals: Yes No Verified by BDM / CAM: Name / Signature of BDM / CAM

No of Proposals sent together: Cheque Form: Yes No

Payment Details: Credit Card Cash No DD

Consolidated Payment: Yes Signature of FC: Yes No

To be filled by the Branch Operations Officer: Branch Ops Checklist Page Count Particulars

Received at Age Proof
Branch Code & Branch on: ID proof
Receipt No:
Address Proof
Client ID: CCR Yes No
No of Simultaneous Proposals: Income Proof Yes No
Product Code: CAN Questionnaire / Addendum Yes No
Address Verified (Mailing & Permanent) Yes No
Is PPH/LA an Employee: No ECS Mandate with

Scrutiny done by: SI Mandate

Comments: Existing customer-details checked with prev policy

* To be filled in by Financial Consultant ** IA / CAO - Insurance Associate / Corporate Agency Officer

SECTION A – PLAN DETAILS

Please select any one option listed below. Kindly refer to the guidelines in page 1 while filling the Proposal form.

Plan Options: Platinum Policy Term: 20 Years
Sum Insured: Rs. 2000000.00
Premium Payment Option: Annual

Premium Amount* (Rs.): 4472.00 (*including service taxes)

Payment Details: [please pay by crossed cheque (account payee only) in the name of HDFC Standard Life Insurance Company Ltd.]

Mode Of Payment: NET_BANKING

Demand Draft Drawn on (Bank name): Cheque/DD No:
Payment Date*: 04-Oct-2015 Bank Name:
(*instrument date in case of cheque / DD) Bank Account Number

SECTION B – PROPOSER DETAILS
1. PROPOSER DETAILS:

Title: MR
First Name: SATISH

Middle Name:

Surname: NAIR

Communication Address:

House / Flat No: A601, Kalash Vaibhav Mahalaxmi

Street / Area: Plot no 21, Sector 11

Landmark: Koparkhairane

City: Navi Mumbai Pin Code: 400709

State: Maharashtra

Mobile: 9004496000 Telephone No (R): -
Fax No:
Telephone No (O):

E-mail Address: [email protected]

Off. Tel 1: Off. Tel 2:
Gender :
Date of Birth (DD/MM/YYYY) : 08-Nov-1980 Male

2. DETAILS OF LIFE TO BE INSURED:
Is the Proposer also a Life Insured: Yes

Life 1: Name: MR SATISH NAIR

Gender : Male Date of Birth : 08-Nov-1980

Relationship with Proposer: Wife Nationality: INDIAN

Country of Residence: INDIA

Most Recent Passport Size Educational Qualification: Graduation
Color Photograph
of Insured 1

Occupation:

If Salaried specify Company Name India Ratings and Research

If Self Employed specify business / Occupation

Annual Income (Rs) : 3000000.00

* STUDENTS – kindly state 1. The course being pursued 2. Name and address of college/institution (excluding coaching classes) 3.
Duration of the course 4. Year/semester/standard * Proposer/policy owner is other than individual please mention Designation & fill Legal
Form

SECTION C – HEALTH DETAILS OF LIFE TO BE INSURED No
C 1. Health Questions No
1. In the past 12 months have you smoked cigarette / beedi or consumed tobacco in any form?

2. Have you availed insurance cover under Stand-alone Cancer product through HDFC Life Insurance Company or
through any other issuer in the Indian insurer market?

3. Have you suffered from or received investigation or treatment for any form of cancer, sarcoma, tumor or pre cancerous No
conditions?

4. Are you suffering from HIV/AIDS, Hepatitis B, Hepatitis C or Liver disease due to alcohol? No

5. Have you suffered from or been investigated for any of the following in the last 12 months? No

1. Recurrent cough, hoarseness of voice or difficulty in swallowing for a continuous period of 15 days?
2. Any persistent loss of blood or unusual discharge from any body opening?
3. Weight loss more than 5 kg in the last 6 months?
4. Any ulceration, growth, cyst or lump in any part of the body?
5. Any persistent headache, epileptic fits, sudden vision loss or hearing loss?

6. Have you undergone any of the listed investigations in the last 6 months (if applicable) No
No
1. Ultrasound* 2. Endoscopy/Colonoscopy 3. CT Scan/ MRI

4. Biopsy 5. PAP Smear* 6. Mammography

7. Blood test for cancer diagnosis (Tumor Marker)

*Other than those done as a part of executive health check or routine investigation

7. Have any of your parents (below 60 years), sisters or brothers suffered from any form of cancer?

8. Has your proposal for life insurance, accident, medical or health related insurance ever been declined, postponed, No
withdrawn or accepted at extra premium?

I hereby declare that, I have furnished the above information, after fully understanding the contents thereof. I have made complete, true and
accurate disclosure of all facts to the best of my knowledge and belief and I have not withheld any material information. Any false declaration
in the above short medical questionnaire may be liable for rejection of this proposal and the contract of insurance shall be treated null & void
from inception of contract.

Place : Signature of Life to be Insured

Date : 04/10/2015

C 2. Nominee Details:

In the event of the death of the proposer any claim payment under this policy shall be paid to the nominee mentioned in this form, in accordance
with the policy terms and conditions. In the event of the death of any other life to be insured, any claim payment under this policy shall be paid to
the proposer. The receipt of the proceeds by nominee/proposer would be sufficient discharge to the Company.

Please tick relevant box : Nominee Beneficiary Proposed Policyholder Client Code (Office use only):
Nominee 1 :

Title: MRS Gender: Female Date of Birth: 20-Apr-1981

First Name: Leenet

Middle Name:

Last Name: Nair

Relationship of nominee / beneficiary/proposed policyholder to life to be assured: Wife

Correspondence Address: Same as stated on page 3, if different then please fill the fields below

House / Flat No: A601, Kalash Vaibhav Mahalaxmi

Street / Area: Plot no 21, Sector 11 Pin Code: 400709
City: Navi Mumbai Mobile: 9769963328
State/District: Maharashtra

Telephone No. (R): 0480-2821357 Telephone No. (O):

E-mail Address: [email protected] Date of Birth:
Nominee 2 : Gender:
Title:
First Name:

Middle Name:

Last Name:

Relationship of nominee / beneficiary/proposed policyholder to life to be assured:

Correspondence Address: Same as stated on page 3, if different then please fill the fields below
House / Flat No:

Street / Area:

City: Pin Code:

State/District: Mobile:

Telephone No. (R): Telephone No. (O):

E-mail Address:

Nominee 3 : Gender: Date of Birth:
Title:
First Name:

Middle Name:

Last Name:

Relationship of nominee / beneficiary/proposed policyholder to life to be assured:

Correspondence Address: Same as stated on page 3, if different then please fill the fields below
House / Flat No:

Street / Area:

City: Pin Code:

State/District: Mobile:

Telephone No. (R): Telephone No. (O):

E-mail Address: Gender: Date of Birth:
Nominee 4 :
Title:
First Name:

Middle Name:

Last Name:

Relationship of nominee / beneficiary/proposed policyholder to life to be assured:

Correspondence Address: Same as stated on page 3, if different then please fill the fields below
House / Flat No:

Street / Area:

City: Pin Code:

State/District: Mobile:

Telephone No. (R): Telephone No. (O):

E-mail Address:

If nominee is minor, Name and Address of Appointee and Relationship with nominee:

Title: Gender: Client Code (Office use only):
First Name:

Middle Name:

Last Name:

Date of Birth: Select Relationship
Relationship to the nominee / beneficiary:

Correspondence Address Same as stated on page 3, if different then please fill the fields below

House / Flat No:

Street / Area:

City: Select State Pin Code:
City/District: - Mobile:
Telephone No. (R): Telephone No. (O):

E-mail Address:

Signature of appointee accepting the appointment:
(appointee cannot affix thumb impression)

SECTION E – DECLARATIONS & AUTHORISATIONS

Declaration of the Life to be Insured and Proposed Policyholder:

* I hereby declare, on my behalf and on behalf of person proposed to be insured, that the above statements, answers and/or particulars given by me are true and
complete in all respects to the best o f my knowledge and that I/We am/are authorized to propose on behalf of the person proposed to be insured.

* I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance
company and that the policy will come into force only after full receipt of the premium chargeable.

* I understand that all information provided in this proposal form and any attachments are material to the insurer’s decision to provide this insurance, and that
insurance will be provided, at the insurer’s sole discretion, in reliance upon the truth of such information

* I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal
has been submitted but before communication of the risk acceptance by the company.

* I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and
seeking information from any insurance company to which an application for insurance on the life to be assured/proposer has been made for the purpose of
underwriting the proposal and/or claim settlement.

* I further consent and authorize any of the authorized representatives of HDFC Standard Life Insurance Company Ltd. to seek medical information from any
doctor/hospital/consultant/insurer that I or any person proposed to be insured has attended or may attend in future concerning any disease or illness or injury in
respect to a particular claim.

* I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or
claims settlement and with any Governmental and/or Regulatory authority.”

* I agree to HDFC Standard Life Insurance Company Ltd. taking appropriate measures to capture the voice log for all such telephonic transactions carried out by
me, in accordance with procedures/regulations.

* I hereby also declare that I have read and understood the products as described in the sales literature and the sales illustration. I have read the entire text,
features, disclosures, exclusions, terms and conditions while applying for insurance.

* I understand that any false declaration or misrepresentation may be liable for rejection of the proposal form or the contract of insurance shall be treated null &
void from inception of the contract. Fraud, misrepresentation/ misstatement, forfeiture, or suppression of material fact would be dealt with in accordance with
provisions of Section 45 of the Insurance Act 1938 as amended from time to time.

Place : Date : 04/10/2015
Signature of Proposer / Life to be Insured Name of Proposer
Name of Life to be Insured :

Declaration made by DDeactlea:ra0n4t/1w0h/2e0r1e5Proposer/ Life to be Insured Assured has :

a)affixed his/her thumb impression; OR b) signed in vernacular; OR c) not filled the application

I hereby declare that I have fully explained the contents of the proposal form and all other documents incidental to availing the health insurance from HDFC Standard
Life Insurance Company Limited to the proposer in the ________________language understood by him/her. The same have been fully understood by him/her and the
replies have been recorded as per the information provided by the proposer. Replies have been read out to, fully understood and confirmed by the proposer.

Name and address of Declarant Signature of Declarant Signature / Thumb impression of
Proposer / Life to be Insured

Please contact us on any of the following touch points if you have purchases the policy Online & in case of non receipt of your HDFC Life
policy document after 1 month from date of application:
Call us toll free: 1800--266-9777 or Email us at [email protected]
Address: HDFC Standard Life Insurance Company Ltd, Online Service Desk, 11th Floor, Lodha Excelus, Apollo Mills Compound, N M Joshi
Marg, Mahalaxmi, Mumbai - 400011, India.

Please contact us on any of the following touch points in case of non receipt of your HDFC Life policy document after 1 month from date of
application.
Call us toll free on 18002097777 (any phone) / 1800228228 (MTNL / BSNL), SMS SERVICE to 5676727 for call back request or email us at
[email protected]

Section 45 – Disclosure of material information:

1.No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy, i.e., from the date of
issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
2.A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the
date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that the insurer shall have to communicate in
writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision is based.
3.Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-
statement of or suppression of a material fact was true to the best of his knowledge and belief or that there was no deliberate intention to suppress the fact or that
such mis-statement of or suppression of a material fact are within the knowledge of the insurer: Provided that in case of fraud, the onus of disproving lies upon the
beneficiaries, in case the policyholder is not alive.
4.A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the
date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground that any statement of or suppression of a fact material to the
expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and
materials on which such decision to repudiate the policy of life insurance is based: Provided further that in case of repudiation of the policy on the ground of
misstatement or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the
insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the date of such repudiation.
5.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.

Section 41 – Prohibition of rebates: (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 in respect 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 liable for a penalty which may extend to ten lakh rupees.

MANDATE FORM FOR DIRECT DEBIT

(Please use a separate request form for each policy)

To, Date: 04/10/2015
The Manager

I/We, the undersigned, hereby: {Tick whichever is applicable}

Request for maintenance of standing instruction for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select banks only)
X Request to remit bill amount for premium payment to HDFC Standard Life Insurance Co. Ltd. through Electronic Clearing Service (for select

cities only).
Request for direct debit from my bank account (non ECS location) for premium payment to HDFC Standard Life Insurance Co. Ltd. (with select
banks only*)

Preferred billing date: (DD/MM) * Policy No. :

Name of proposed policyholder:

Name of account holder (if different from above):

Premium amount to be debited: Rs.

Amount in words: Rs.

Bank A/c no (from where premium will be debited):

Bank name & address:

9 Digit MICR no. (not required for SI to HDFC Bank Ltd / Direct Debit from bank account of non ECS location):

Frequency (Please tick): Type of account: Savings

Account holder signature: Date: Place:

Proposed policyholder signature*: Date: Place:

(*If different from account

Relationship with account holder (If proposed policyholder is different from account holder):

Reason for payment (If proposed policyholder is different from account holder):

*Kindly check overleaf for the terms & conditions, Kindly submit this mandate 30 days prior to the premium due

(Please refer point 8 of the declaration)

For office use only

* Next premium due date: Last premium due date: Policy number

Account number of the beneficiary (with HDFC Bank Ltd):

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CUSTOMER ACKNOWLEDGEMENT

Date: Frequency of Payment Term
Plan Name Amount (Rs.) Bank
Cheque / DD

Other requirements (LIST)

1. 2. 3.

I, have collected the above documents and will be submitting it tothe nearest HDFC
Standard Life branch for further processing.

(Signature of Financial Consultant) (Financial Consultant contact number) Financial Consultant Code)

> This is NOT A PAYMENT RECEIPT but only a proof of the documents received from you. > All cheques/DD should be crossed and drawn in
favour of HDFCSLIC. > If payment is not made by way of Cheque/DD, Kindly make cash payment at an HDFC Standard Life branch and collect
your initial deposit receipt. > This acknowledgement does not in any way constitute acceptance or commencement of risk.

Easy Connect: -
If you have any queries or clarifications regarding your policy, kindly contact us at any of the following service touch points accessible from 9 am to
9 pm all 7 days, alternatively you may e-mail us at [email protected]
@ Call 1800 266 0315 tol free
SMS ‘service’ to 5676727

Dear _______________, we acknowledge the receipt of your SI/ECS mandate and it will be processed within 30 days from today. After attaching the same in our system, we will forward it to your
bank for further processing. In case of rejection, the same would be communicated to you; or else it would mean that your mandate is lodged in successfully.
Effective the next due date the premium would be debited from your bank account. Thank you for choosing direct debit as your premium payment option.

Branch Stamp Acknowledgement received

(Signature of the Customer)

Continued Overleaf

DECLARATIONS FOR DIRECT DEBIT

1. I/We undertake to keep sufficient funds in the funding account on the date of execution of standing instruction.
2. I/We hereby authorise the bank / Bill Junction to communicate my/our funding account number and any other account details (as may be
necessary) to HDFC Standard Life Insurance Company Ltd. for the specific purpose of recovering my/our HDFC Standard Life Insurance Company
Ltd. premium payments through a standing instruction of my/our account.
3. I/We hereby authorise HDFC Standard Life Insurance Company Ltd., in the instance of the Standing Instruction / ECS debit failing for any
reason, to authorise the bank / Bill Junction to recover the premium payable through a direct debit to my/out account with the mentioned bank.
4. I/We agree that for changing the premium amount as per my requirement, I/We will furnish a fresh mandate for such change in the premium
amount, which will supercede all other mandates previously given..
5. I/We agree that in the event of any violation by me/us of any undertaking confirmed in the agreement herein shall amount to an event of default
in the terms of the Insurance Policy and HDFC Standard Life shall be entitled to invoke the remedies available to it in terms of the policy
agreement.
6. ‘I/We agree that in the event of the bank being unable to debit my account for want of sufficient funds or for any other reason, HDFC Standard
Life shall be entitled to deal with my policy in the manner as described in the policy provisions, unless the payment is received by any alternate
mode on or before the specified date.’
7. I/We undertake to revoke the Standing Instruction in the event of the policy being ‘withdrawn/surrendered/lapsed/terminated’, where any
subsequent amount is debited to my account due to the reason that the SI not being revoked, I/We shall only be entitled to a refund of such amount
on my/our demand and no interest or compensation is payable on the same.
8. I/We agree that the premium will be debited starting from the premium due date / preferred billing date which occurs after the date of this
mandate, till the last premium due date unless the mandate is revoked.

a. I/We agree and understand that “Preferred Billing Date” should be within 30 days of the PTD and will always bebefore the PTD.
b. I/We agree that the premium will be debited on the “Preferred Billing Date”, if opted and this date will not be revised till the last premium due
date unless the mandate is revoked.
c. I/We agree and understand that in cases where the Preferred Billing Date is opted for, and if the payment of premium by such mode amounts
to advance payment of premium, then such amount will remain as an interest-free deposit with us and will

Note:
* Premium can be paid out of your own account or out of your Spouse, Parent or Children’s Account only. * Any cancellation, correction, alteration
etc. should be countersigned by the Account Holder. * Kindly ensure that the SI mandate form is signed by the account holder, even if the account
holder is different from the policy holder. * If the bank is unable to debit the account of the Policy Holder due to want of sufficient funds, the policy
holder will have to pay the premium by cheque/DD or cash at any of the branches of HDFC Standard Life Insurance Co. Ltd. before the grace
period ends, failing which the policy will lapse with/without a surrender value as applicable. * HDFC SL has the right to revoke the Standing
Instruction on event of the Instruction or change in the premium amount due to any alteration. * Direct debit facility (non ECS location) is offered by
ICICI Bank, Citibank, Corporation Bank, Union Bank of India, Bank of Baroda and Axis Bank only.

To be filled in by the account holder’s bank

Bank Stamp Date Authorised Signatory of the Bank

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Introducing you to our wide range of value added services.

Track and Trace: You can track your proposal status online: -

1. Log on to www.hdfcinsurance.com

2. Click on ‘My Account’

3. Click on Track Your Application

4. Enter the 16 digit application number (on the bar code)

Hassle Free Options: -
Your policy portfolio now available at your fingertips!
‘My Account’- your very own customer portal

‘On the Move’ - avail of policy details on your mobile,
just call our contact center or
sms REG<space><policy number> to 5676727 or call
our contact center to register for this service

Premium payments made easy: -
Standing Instructions (SI) - a direct debit facility for all HDFC Bank account holders.
Electronic Clearing Service (ECS) - an auto debit facility available in more than
50 cities across India*
Online payments - available to all policyholders registered with billjunction.com or have
net banking facility. *
*Kindly check with your financial consultant to see if these services are available in your city.In case you wish to avail of any of these services
kindly fill in the service request form in the proposal document. If you opt for electronic clearing service kindly

Correspondence Address: Customer Service, HDFC Standard Life Insurance Co. Ltd, 5th Floor, “B” Wing, Eureka Towers,Mindspace complex, Link Road, Malad (West)

NRI Q - 6.6
FC Code No:

Non Resident Indian/ Person of Indian Origin Questionnaire.

We thank you for applying for an HDFC standard Life Insurance Policy. To enable us to assess your application, kindly send this NRI/ Person of
Indian Origin Questionnaire answered by the Life to be Assured and duly signed by the Life to be Assured and Proposed Policy Holder, if any.

Application No./Proposal No.
Name of Life to be Assured

1. Address of foreign residence.

2. The name of your regular medical
physician while abroad, with full
contact information. -Telephone No,
Address, E-mail address, etc.

3. Permanent address in India.

4. Nationality
5. a) Date of first leaving India.
5. b) Date when you intend to leave from India after
your current visit.
6. a) Duration of your stay abroad.
6. b) Date of return if known.
7. Purpose of your stay abroad.
8. Name and address of person to whom the policy
document is to be sent in India?

9. Please state your NRI Bank account number and
the name of the bank.
10. The source from which the premiums will be
paid?
11. a) Passport / PIO Card Number.

11. b) Date and place of issue.

* An incomplete Questionnaire will not be considered valid.

I agree and understand the following:
1.The information given herein is true and complete in all respects and will form an integral part of the proposal made by me for an Insurance
policy from HDFC Standard Life Insurance Co. Ltd.
2.The policy as and when issued will be delivered to the address specified in Question No 8.

3.Similarly, the claim proceeds under such policies will be paid in India in Indian Currency.
4.The product has been sold to me in India and the proposal from is being signed by me in Indian territory.

Declaration of Life to be Assured:

I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by
me for an insurance policy from HDFC Standard Life Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate
the contract.

Signature/thumb impression Date:
(Life to be Assured) Place:

Signature/thumb impression Date:
(Proposed Policy Holder if different Place:
from Life to be Assured)

In the case of thumb impression\ signature in vernacular language:

In case of thumb impression of the Life to be Assured the same should be attested by a person of standing whose identity can be easily
established, but unconnected with the Company and this declaration should be made by him.

I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language and have truthfully recorded the
answers provided to me and that the Life to be Assured has signed /affixed thumb impression(s) above after fully understanding the contents
thereof.

Signature Date:
Place:

Name and address of the declarant

In case of further clarification please contact your FC/ BDM/ CAM/ HDFCSL Branch office.

e-Insurance Account (eIA) Opening Form for Individual - To be used only if submitted along with the proposal form

Application No. / Proposal
A. Select the preferred insurance repository in which e-Insurance Account (eIA) needs to be opened:

B. AUTHORIZED REPRESENTATIVE DETAILS (mandatory) Date of Birth* (DD/MM/YYYY):
Name*: Relationship with eIA
Gender*: Mobile No*:
Email ID*:

Address*: Same as eIA

City: Pincode:
State: Country:

I wish to notify Authorized Representative about his/her appointment

Authorised Representative Details for the eIA

An Authorized Representative is like a trustee to the e-Insurance Account (eIA) and has to be deputed by eIA holder. An Authorized
Representative is a person appointed by eIA holder who can access eIA in the event of the eIA holder's demise or in his incapacity to access
the eIA. The Authorized Representative can only access the e-Insurance Account and know the portfolio of insurance policies.

Declaration

The rules and regulations of Insurance Regulatory and Development Authority & Insurance Repository pertaining to an e-Insurance Account
which are in force now have been read by me and I have understood the same and I agree to abide by and to be bound by the rules as are in
force from time to time for such e-Insurance Account. I hereby declare that the particulars given herein are true, correct and complete to the
best of my knowledge and belief, the documents submitted along with this application are genuine and I am not making this application for the
purpose of contravention of any Act, Rules, Regulations or any statute or legislation or any Notifications, Directions issued by any
governmental or statutory authority from time to time. I authorise the Insurance Repository to send any policy and account related information
through email and SMS on the contact details given by me. In case of any physical policies being issued by the Insurance Company from
whom I obtain an epolicy, the address in the e-Insurance Account shall override the address provided for the physical policies. I understand
that all the communication relating to any physical/ e-policy will be sent to the address registered with the Insurance Repository. I agree to
inform the Repository of any changes in the details mentioned in this form and in case of delay the said repository shall not be liable in case it
acts on the said information which has not been updated. Further, in case I update the details with the Insurance Company, I authorise them to
submit the same to you for update in the e-Insurance Account and the said update will be applicable to all policies of any insurer that I hold/ will
hold in the said account. I authorise the Repository to pass on the information to any Insurance Company that I have approached for availing of
insurance cover.

I further agree that any false / misleading information given by me or suppression of any material fact will render my e-Insurance Account liable
for termination and further action.
I hereby authorise the Insurance Repository / Insurance Company to disclose, share, remit in any form, mode or manner, all / any of the
information provided by me to the respective Insurance Companies and / or to their authorised agents and representatives in which I may
transact / have transacted including all changes, updates to such information as and when provided by me.

I hereby agree to provide any additional information / documentation that may be required by the Authorised Parties, in connection with this
application. I hereby confirm that this is a unique e-Insurance Account opening application and I have not applied to the same Insurance
Repository or any other Insurance Repository for an e-Insurance Account in the past.

I would like to receive my insurance policy and all the information related to the proposed insurance policy through Insurance Repository.

I am aware the details furnished by me, including KYC documents, in/alogwith the proposal form will be used to open the eIA. I hereby give my
consent for the same.

Name of eIA Holder Signature

HDFC STANDARD LIFE INSURANCE COMPANY LIMITED Call 1860-267-9999 (Local charges apply). DO NOT prefix any country
11th Floor, Lodha Excelus, Apollo Mills Compound, code e.g. +91 or 00. Call centre is open all 7 days from 9am to 9pm
N M Joshi Marg, Mahalaxmi, Mumbai – 400011 SMS - SERVICE to 5676727 (Charges apply)
Regd. Office: Ramon House, H.T. Parekh Marg, 169, Email – [email protected]
Backbay Reclamation, Churchgate, Mumbai – 400020 Visit – www.hdfclife.com

Customer input PAN Details of the Proposer/Life Assured

Given Name: SATISH
Surname: NAIR
PAN NO: ADZPN9169R
Date of Birth: 08-Nov-1980