IRDA (Standard Proposal Form for Life Insurance) Regulations, 2013

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Tfrrc# TT° ^sto-33004/99 REGD. NO. D. L.-33004/99 of Jjudia EXTRAORDINARY STFTIII— 4 PART III— Section 4 mf«T^TT ^ Wilfrid PUBLISHED BY AUTHORITY 45] WlHW, <+><dTfr 18, 2 0 1 3 / ^ 29, 1934 No. 451________________NEW DELHI, MONDAY, FEBRUARY 18, 2013/MAGHA 29, 1934_______________________ <s(lni 3ftr fsrarrcT 3TfsR^nT l<UMK, 16 2013 •gtm rdpH^mg; 3frr f ^ r c r (*ftcR t ^ f?nT t t r c f tpprtt^ w f ) f a P m , 2013 tpr. 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L.-33004/99 Chi [:he (Ga:i.ette of ~ndia ti. 451 No. 451 m:mmur EXTRAORDINARY mlflll~ 4 PART III-Section 4 ~ ~ w cfi I ftili1 PUBLISHED BY AUTHORITY ~ ~ . -mi:rcm, "tfi'tcm 18, 2013~ 29 , 1934 NEW DELHI, MONDAY, FEBRUARY 18, 2013/MAGHA 29, 1934 ~ 1&1-i<.11~4i 3ttt ftrcnm ~ ~. 16 'fl q1, 2013 ~ fctf➔qi4cfi 3fi'{ fcfcnm ~ (~ ~ ;t- ~ '4'Acti ,;rn:J1q 'Qiflf) ~ . 2013 'tfil. lt. tilt.nt.nt:i:rr.~110168/ 2013.-~. _mt3iITTRT ~ 1999 ~ URT 14 (2) (b) (1999 cfiT ~ 41 ) 3ITT ~ ~. 1938 (1938 cfiT 4) ~ - 114 (a) (~) <'Im (~) c)i ~ -..c.c-(1 ~~ cfiT ~ cfi«l ~ M •He>tl(\cfii{ ~ c); ~ tR"rn~T ~ , Qc'W;_ql{I ~J-aiffirulc-i Ul~~'1 ~ ~ WM, 1. ~ itfi,r,.f;' ntlT ,;rm:3T (1). ~ ~li14'11 cfi1" m fcH;i.Q1cHcfi 3ffi fa&iffi ~ f;;ftqc;:r ~ c); ft:lv '1101cti ~ ~ fclFv!.QcH , 2013 c); ;:rr;i:r ~ qq;m ~ I .:, 2. ~ (2) •~q;1~tr' cfiT 3TTmr1<T lT<f> ~ ,Q'l ~·cfi1t1~t1 m ~ m lT<f> M ~ ~ ~. ~ ~ ~ .:, ~IT ~ W~ a'!" t, c); c;cfffi ~ ~ "JTt ~ cfiT ~ ~ ~ l"fi c,Qfc@ ~ c)i ~ "Q"q; ~ ~ ~ cfiT ~ (\~ ~ q~OllcH ~ c); 3ra_PITT" t I 656 Gl/2013 (I) 2 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III—-Sec. 4] (3). 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Tiafr ^ 3% §rra sit yqfar fa^t 3ttt ^ 3 ik q t^ fif^ r ?rfr fazt 3 fa s r ^ r t 3tfttf?pzOT, 1938 (1 9 3 8 #T 4), 3IT 3frTT tW f W I ^ 3ift fafTO q rftJg^T ail^QiTfl, 1999 (1999 % 41), 3ffc 3 ? fa 3Tttor 3tt f ^ r z m t # q ftw fa d fa^r w % 3T^ ^ t § t : g fr ffarr 3it f a 3H 3 iW ?R m t 2TT I^Tffr <51 tWRJTfr £ 3T3TT t | 3. 59T f^rzmt sfrg^r ^frrr 3^ c2rfa=PTfr qT^ffr % f M #r ? t r ^ y-^Hicj tpf^- ^ r r t | t^ R fa 23HT i T ^ r f W / t ^ r 5TFRFlfr ^ 3 ? ^ 3ftT # ^ f l ^ t ;5 ^ g ? r #T IcHT 17^ ^PcH^d orcftoTPTST % 3lk TJ^T 3^1^ # 5TRcT ^t Wq^T f M w f? R T 3 ^ 3 1 ^ 1 ?t?fr ^ | Htir srrdt f M f ^ r i ^ r ^ qrerf^THT 3ttT §ff3t % f^ it # TOTT # 3TI7fr ^ | 4. -H^+dl ^r f ^ r ^ w y w w gTortns# #r % srt f a ^ t c t , ? t^ w ^ W ? n w ?n7 5Tt fa f^iKT: 3TftJ^nOT, 1938 # tfRT 45 ^ 51 d^TT 3Tlt3TRfKT (qrffMttJR^t % IfTdt ^RT TTOFT), 2002 ^ 7 (d) ? 4 3lk ^tnT f^OT ^T ?m?T 12 # 1^t 3TC- ^ | 3Tt.-^rnT - II :5T^r?g- 5. vra'i^cfT atk a^r (1). ■ZTf IWrZOT 3ftcT5T ^WT chMplijl S^TTT 5I7ff faV 3W ^nfl c^ftdJIcT qff^tf^ft qT cIT^ ft^t 3?T Roil fa?ft icHIc; ^T g^TT ^ <aUs gft WnfaT ^tT] (2). f?r t W r n t d?cr ^fr tiif^Trci qftmrf^td- fa^r ?nr t ^ ^ p f r 3^ r m ^trt m I 2 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III-SEC. 4) (3). •3q4cfc1c11· cf;T .mmm:r ~ ~ ~ fcl:i ~ i;r@1q q;rn- * er ~ "3ff-,~ ~ 3fJtm" ~ .:> • ~ ~'N mcfr w-& ~ ~tfur'R f<mul, ~ ~. ~~ ~r cl, mm cl, .mtw uq; xGR ~ 3TTcf1" ~ ~ 3ftln f,f-11 ( I .;) . 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Ji't.ij~I iftJIT ~~ifiT;fm' 8:\'J@Tir~ ~lt :m-Rl5T.fm lfilc'ffif firi· -;;n'lf ~ (ll'Jt iilH'l"idlfi m ~ lfir ~or cll'lt'~~mm ~lfiT~ ~~ cm~ ~ cm~ <F. ~ N. ~~ - 11". ~ffflioo ~ - Q". ~Ji!'~ s-. 3r~~ 1Fir.T~~ l 10 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— Sec. 4] U t w ^RdT 3ftT $ ^TFFnf^TT c?rf^RJt # 3fR £ sfRTT fa^TT oTToTT t 3T<Wd # f^T TOT sTOW, 3raT«r 3tft szfft 3ft tTR #T 3TSRTTT *T3fr £ 3" i? $ / fPT 31°-^ ci|[cfdill 3TtT } t y+dM f^TT 3ff^!^cT|Vfi | ^•H<H^di i M o T i t r ^ r t ? i t d i ^ i ^ #?<sfi<Hi qffpRfl m 3m jTT!tW ^3frr w Trff?Rfr sfrf s^ttt 3wrrtfer «fmT # atfrrfft^T qff^tfr ^ 3tffcr I q?T tfrf^rzw F^r <tt £r qfi^Rfr tot* ?Wr # / EOT 3TT3t ^Tt^iTT f a 3fyeT3T ^ T T / ^ T t y fd ld ip q^xTRT ^RH tRTT SRJ=cpfr ol'lf^<H <-41<*>lcl % ■H^IK nUdc^ol sTlftld c^Rd/^TTtT ^rlT ip cZmFRT ^TT fa^fRT fgrF^T W ^TTJTT^ W T m A gtdT t \ / £><H t i l u 11 ^tTRT 3 t t T ° F > t ’d$<Hfcl ^dl i? ^-cTR-^zr ?t -H<^-sif?]d oii«i«t>i0 3fi-5I^CT^r5JTTT^3fFTdTcfS" f^RT^T fa?fr 3fr 7RRT q i c^RVi h %TTcft #kTT HRT faziT f t 2]T f^Rfr §3t 3TcflcT ^TT cTefcTToT Pl^'l'+dl ?t sfTf^cT cJjf^cf / STTcft shell ^ TR-^ttJrT ?il'TlRch •JIT <Hm[?I<+i ■HiI<"^1 olM<+>l'fl 3TPft oTT •d+cTl 1? o ft y W f^ c T ^ R ^T^cfT (-T 3JT I^Rfr3 ft^ t^ T T ^ iR lte R r ^t«S)i*-ld cill^d I STPft sbdl % «T|J-II ^ 3HcR'4ct> olM+i^ «hidFl oTT •H't'cTl f? oft f^T M-4-dIci *£r 3T?TTr?ft ji eat ip f^qrcw ip TOtoR ^r ?t ^ y rd ra r^ r oim+ i^ ?rf^r fajEfrsfr ^R^rfr 3ttr / ^it Pi^ii-Hch ^ ^trt ^ i ^ M - y c w on vrttTT ^ 3101101, ^txtsti ^ t 3 llc ;w -y c ;M y -W M ^ t 3 lS « l$ f ^ dl 3 ftr S flt ^7 PiMC.I<r! k,cb<Hl ^ f?lk1 oTT •M ^ d l f^STRfi-:_____________ (yTHTcr+ ^ ? T c n m /3 ^ itw q f5 r? ir a o (TfxTraV ^FHWT) (JH^ld SJrf^cT % 5VcTT8TT/ 34Jli^ * T l< H ,ir f ^ 1 TFH79V^3T5T*T ?t) (tflUfcT c^ (^ d #»!R=cTTyR,^ S < 'K ild « t.^ 3 rg P r ?t) IO fflVIT: THE GAZETTE OF INDIA : EXTRAORDINARY [PART III-SEC. 4] ~/pr Qcit~<m, ~ <fi«TT ~~ 6 ~ ~ mnt .,fit~ S1fc1,fac1 ai~a.d1 ~ 3-llnt~ ttm ~ aro,r 6 3q:i.1ctc1 * ~ mr ~. acrrar 3fit ~ ~ ~ ~ 3faffiR mfr !,jq,1< ~ ~ ~ <f ~ ~ tr/ pr~ c.ti f~c1 .ti1 ~ .mnr ~ ~ ~ 3ITTl<fff ~It I ti' -w=i~ar~fcf;-~ ~Ql(I ~T ~ ~ "1 loicfilfl ~ ttm ~ qif 3n•m~ ~it"atr 6 3~( ~ ~ iift-g c.<mr ,j1•:fH1R.c1 m- ~ ~ .31-f{l$R.,1 ~ ~ .mfto:r ~ I 'iiTu-t11 lfiT ~ ~ ~ ~ ~ ~ ~ ~ ei'rn'r tr I pr 31m ~ {~ ~ °tf /p:f ~ffic1 ~'-I ~ ~~c1 ~/cfitit ~ ~ ,ti~~Ul ~ ~~ ~ ttm cf>T-q;fr ~ ~t<1"1q,1a <iilfflRti'-l(;M ~ ~ '-l~QAo1 ~ ~,3TT<ft ~ ~ ~ ~ c,Q <lfli .tl <IT ~ ~<f ·~:u fl IJ.llo-.tl B:l'TfUf-ar ~ 6 I ~ / ~~ Cfi«TT {~ 3fit~ <m ~ ~c1T ~ ~ ~ ~ ~~ ~ft«, -11fa1<t>tfl ~ 3fl"~~<ITt!"cfi".:ttf9c1iC't6 ~ ~3fl"'fl"J.t<rq-:i_-~ ~ / ;Wd't ~ Cfif $C'11"1 ~ ITT <IT ~ 3fl" 30'ic'f <IT ~ ~;zi'1ctc11 ~t ~c-l ~ I 31rcft ~r ~ ~ ~rrfl~ <IT ;i:n.,fwf; BilfUf -111o1cfil fl ~ ~ ~ 6 -;;it ~ ~ ~ ~ <IT ~ 3fl" trn"I cfil .tl'I C'l .tl l~at'l~c'f ~ t 3TTcft ~ar ~ tlJ.tT ~ ~ ~~ ~cfiffl-~ ~ {-lq,c1~ ~ 31)- ~ \,H-c11q ~ .:t1sH1$R.a1 ~ ~ ~qc1o1 ~ ~ ~ ITT ~/pr~ qi1 .IDU<fc1 ~ ~/6 ~ i;r@lcf ~ ~ -11lo1cfilf1 ABcfiM f(q,y~ ~ ~ 3fl" ffiCfi°rtr 3tR° / <IT ~<TT°Jrcfi ~ ~ ~ 3-TTcJif-~ f'"<rr ~ flcfic1T 6 ~ 3-iC'IICII, ~ cliT 31 c~lo1-1RJai i;r@lq~ 3-isHt~R:dl .,fit ~ ~ ~ ~ Q7:Fi".!=!Nffl7T~ ~~~fl"cfi'c1T6. ~: ----- (t,ifcijqcf, ~~ f't V a a *> a £ i 4 5 a 9Aa i•w -a.i J s * i S') ui| 01 51 <*|.i * si. 4 MX 1 1 1 I » I I i ai & 3 91. i 3> 5> | a 2 , 5 a Wb t r 5 ' 3tP «±f a ) ■9 a a i i ± > fehkll life Mh [fr ?n!5>— 111 Irik] 1 I ! tr ~ ( ! i ~ I ~ I . 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I I i1 Ii I Ii ~ ~ j i i t i ~- t ~ ,4f f ii t t ! ~ i· I i f I ·I I fi I ., t 5 I ~ ; fi ~- ., Ii m ~- I 1, Ji ii Ji l : 4 i i 4f m ! d ; ~ i ti t ~ -i ; a 1 i i• l l! I !~di i Ii ~ ~ ! i t i ! ~ ii i ~ ~i j ll ~ ff ! I t ~-~ r jl i ...... ~ ~ ii ( I f ...... fl ...... ~ ! i ii 1., ii 1 1 t I 1 't 1 1 i ~ :1 i i i ~ i ]1 ii i i ~ r m i i i! i r m i ti tJ to !Iii Ni s= tc ~ ki :;i 12 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— Sec. 4] ?r. jr it 3nq^3;'»ft vq-^f.Hf^iY+%pld?r R + i< 1i<t.r?n«flT<*>wi,T3r, ^TT -fla ps^l, oils'!, 3Tflt, 3JT5>'6:5 0*T^Tf^>+f! Sft3i<r<t fefaTTT ? / »l^1 5J. w, 3iih«1 ^TSft fa>*fl 3l«-*j «n*nfl <TT<j«ic>tcii 5>T ^TT^TSTT ftioi ^ 3ft 3^ 7 ST^t 5 T / n # 2. / 4>cJ^ c<4f^-cl = f i T d A u 1 “F. <t<ll 3TFTfl(l<il*l ^T<l3^cld1 ^7 ?t/5T# 53T. ^I2l JT, 'i4f"io<-^i ac^*ii»i *1^1^ 3T. 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W j p j 5 m R aflr stfft fit TfRr #r 3 r w t w lr £ <r V r £ | ci^Ki iqcHstr^RTf ^ o f R + r t t ^ ^ i ^ a m i R ^ f r /{?3ftr *r? qrfiWr 5mrr aw Jitfer $ m # 3if-ii$ftj| mTPi^I #r 3rtfr?r | qffottfr qrr dtf^rzw vn^r ^ q r qffiWt rar^fr fW t # / ^3T 3TRt ^ rm \ %/t # / iF T f o lf ^ d WJ t ^TftTcT ^ C T T / ^ t ^ y f H I 3 «H<H^UI ^ ^xTTcT sfrnr w rrq # ^ % # m r £ q ^ r ^ ^ q ftcr& r czjf^ r /w f r &?rr o2J^BRT ZfT fc||f%3r?TT^|<HI^ ^IcTT t | # / n H w aifc- # ^ ? r ^ & tt | % <jf 5T R ^ itr f^Efr §fr S T ^ ^ T ^ T ^ anRcTTcTf? f^W^T §4T^PRT^Tf^TFr cJjf^T/3TT<fr &clT feTT3T fe^TT ^ 3T fo tfr sfr 3T^t?r m g ^ M P raW ai t W t t c ^ d / a n # ^ r r £ ^r^fsJcT fiM fito sT R ^ itr Jifsfr srr ^rentr t ^fr ^ t t ^ t w r - ti^ f# % m c^ ^ f/jfT ^ r #5?u % tr?TT f M a r r a ^ ^ s rR ^ ifr t i t # srr ^ c t r ^ ofr w a r a # 3T3TTTffcT 5T# #7 f?N£l<H ^ y # 5 R ^T fff 12 2. THE GAZETTE OF INDIA : EXTE.AORDINARY [PART III- SEC. 4] .,_ <RIT 31'fq ~ ;f;'lft ~ . ~ 'lfn5' rt~~ ~ A .ff ti!'l+:4i~ c.l'I fctm ifiT ffl1JiIT ifir.IT tf'1°, ~/~ ftff'm~~~. m~. 3nit, illif>Tc5' {lar~~-aft ~~? . - . ~ o:i. <PtlT~if;"aft~·~il'lmftill~ lf>T ll1lTrTT ~ t ~ ~ 3tl"{ ~ ~ 'lff ~ !.rt!' ~Qfiildcfi/cf;?rf ~ifilfhlul" i!fi. ~- .Y. 'ET. s·. ~- - 'RT 3ITQ' ~~ JJncft·f? ~/~ q~~. 1Tlfil!l~I t-~~~ ~ a1lfjl!l~I ifiT ~ cRIT 3ITQ'ifiT ~ aft ~. mt'tlrcJ ill 31 ~ I f.l cf, ~ Jlll '1T ~I.rt!' ifql 3frCI' ~ -aft~mr it>1 ~. ~ ~. ~3JT1f m 11T<1)~· .,.~~-~~-;;it-a- ~/.rtt iti"Uf t ? - IRI I' 3'1l'tl.t cfi1ft' ra.i· ~ Qif;" 3ffrl~cffll' .#:t cl~ ~ ~ ~ ~ miri~ ~. mf;t, ~Tlf, ~/~ mn:r, ,o1·1~q., ~~ ~ tm, ~ 1;1l«f, '1J'1n'a"ftlT ill~~ 1;1l«f ill 'Qq;' ~ ~ {1'1f t-mr.r~t1r<lT3IT? tt 1 ~ Q(i~cm.l 1:TT"fUTT cfl«TT (;~ 6 ~ AA .mnr 3th'~ SH-("ilfcl("i ~ l<f(iqJ cf;r :mnr ~ ~~~6 39.(~cf(i ~ ~ 'lJ'Q' 111~1"1, ~ 3fR~ .tt -ma;~ 3ioIBR mfr 'SfcfiR * ~ ~ i:f ~ 6° tt / p:r ~ C<41'fc1~i ~ 311nr ~ ~ ~ ~ !~ I 'A' :fil1$-l("il ~f.\;'~c;,_qm~r~'JT$' ..,1,o-1ch1~l ct~~q;r :,mm-~11' ~ JttT ~ tirfmfr iM c;qm 3-lcriJ-Me;a .frm cf.~..f, cfi'1" 3iJHl$fea1 ~ ~ ~ ~ I ~ ~ trU ~ i;rrq:r ~ - ~ ~ ~ tr tfffITTfr i;rn-rcfr Wfr tf I ~;i, 3ml ~ wt ~ tf /P, ~ ~ ~ ~ ~l<fitir ~ t;f@lcf ~ ~ ~'t1'IB trta ~ ~ ~ ~fd'l<hfa ~~*~ ~ ~ q~c1c-\o-1 ~ ~ /m<:ft ~ ~ <. tf / P, ~ {/t ~ ~ cfl)" ~ ~ ~ ~ ~ ~ * ~c1 -511o-1<hlfl ~ 3ft' sfifc{~m'Qcfl 3if9("ilc>l ~ ~ fcRfr3fr~qz~ ~/m-8r s),"cff '<hT ~~ITT m ~ 3ft' ~ m ~ ~41cf("il * ~ ~/:imlt ~ ~ ~ ~~ m c1-lla1m<h ~ '511o-1<h1fl a::ffaiT '51T ~ 6 '3TI' i;oofct;~ ~ 6° m f'~J, afratPTT ifil4h,t4 trtITTIB ~lm-8r ~ ~ ~ ~ fc;l<)- .Jfm~ '5llo-1<hlfl ma'fr '51T ~ 6 ~rr ~ ~ cf;r ::tisHl$R:a, c;r& ~ ~;:1qt:,1,r1 ~ ~ * ~~r Lnmr i n— 4j 13 3 ^ y fd N ^ T ^T3=^ftJ^T 31T7TEBT?I ^T|<+kH f ^ f t 71%? f^ fT §fr 'tK'hlO .jftT / 2|T P|i||<H<+> yiRjch^l -fH^T 3llc;i<d-Wcil<r( i|| 3TT TT^xTT (? 3foTT<3T, ^pcJoTT 3 tT 3flcJW-SfSW y'f'dTW^r 3T3TTTfft?T 3#T 5T# ^ f^PTCM % |j J&7J # 7 ^ 1>^I 3TT TWHT %. % ?THTWT/3Pjt: 5TT frRlTST (y4niq«t> % JTHTCffT) (tTf^TcT c^jf^cT%■ fTcTTW / 3WI& 5TTfrl^lM, ^Tftf y«-<-il<J<t’ 3T5TJT ft) cilf^d q fe H +dM * 1 3T?PT ft) 3T*rT§H |d| - I f - 3 TnT9xTcTT^>T f c U ( ^ ul o o ( 3 W 3 T ^ r f ^ r c r ) 1. d $ d <^*<4 3T9lc»M- a c ta i*i 3^T3W<FTrf*tH <ft) a * fasti •«!« vH5j^glt' 5-xo Tira- 10-15 3^t 15-20 *TT5T 20-25 *T5T 25-30 STcr eilT^«r» W. 2. 3 T P T « b l < J < b l t f 3>t 3Tftto2J^cT «*><<} |j? d *fi # r « «s*i i 5?rit lO^TToT 15W7T 20 3TToT 25 W 30 -Hl<*t S'. 3TcTRJ'^>T^ 3. SUM / OUH - < j& R R 3 fU 31 A lfa H (* M « X ) PhSol- ■Hlet *<lrt 5-10 3TT5T 10-15 3^t 15-20 *TT5T 20-25 *TTeT 25-30 *11 cH ?r. 3 m o', ' IS£6'/12- V . I . I . l L 'IWT lll-- ~ 4 J °if / Pi~~~ ,t-1,{ctilfl MR/ ~I Fo¼iJ-lcfi ~-~rn~.:ti ~ : ~ {ft Jttrn~ ~ '7ilcrlcfilfl A~cfici! ft<f;g ~ ~afr i;rrRlcRurc\:i" :m~ 3fl~r.=r-~~rv; ~ '7iT ~ t ~ J,c;TraT, ~<fir "' sHl$R.a1 MR~;\:;" fa!lqc:1o1 c\:i"~m~c\:i"fITT!~'51T~~- 13 3tcrt .:, lfltil - if - 3q.Qcfddl iliT ~~r .:, ' c~~ifllaJ ----------------------, 1. a~;r ~ ~ ln'1Tif- ri ~ 1mi[.ri 5-10 fflel" 10-15 cJ1ll 15-20 fflel" 20-25 fflel" 25-30 ~ ~ if>. ~ I ur. JJTh ---· 3ffq' ~lfil~~llil if,°t ~ z. 7 if>. a~l~Rlft" 5a,iil l0ffltll" 15 ~ 20llllf 25 fflel" 30 lllif l51°. 3faflt~ 3 . 3ml" / ~ - aa1t1-, MR ri llli[.ri 5-10 ~ 10-15 15-20 ~ 20-25 ffl1lr 25-30 cJ1ll llTN if>. 3ml' l51°. ~ t5/Gil//3- l/ 14 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— S ec. 4 ] 4. T^cvTl*! f ^ c H u l w . *w 3T. artffrcT 5. <£l oWTH <£r qfyRT 3^0 9r 3fr<jii «fTJTr (jjr^ / <77iiW%V 2T ■MIW-lT^tJTT wf^cff cfi&rffcr■tfjw f zr. «cud jftr M v dllvid)*i fieri ET. ^iltM iTloldl h I7)a4 altirfjq JV/W 6. ( h k h U« t> / / 3 W T / ^cTR-S^T) 3T. c oTT*T 3>T flUT S . sfif*l^*l ^ y«M< 1 ^r. KTTHTrrn'ry (yuiicTl) et. J H J id id ^ r f ^ - 5 . ira fa - *T. «fc<Aol 3raft}" 5T. HIJT / < I5 S ^ / 4>S TT5rt^>?I3T 14 THE GAZETI'E OF fNDIA : EXTRAORDINARY [PART Ill-SEC. 4) 4. fc!l«fl~ fc!l~~OI cfi. ft'ifm~~~Cl'<N~ ~·. ~ .. ~.r~11•i ll'if~ - lf. JrCttirn ~ '------· --L....- - -- ir.l' (1J:~ "lliR!lcl1) ~'ihlriltf1rrr 1T. ~l~cfifmr ~ ~~itirr./tlr#tm· / 7f. m~r~ ~~fmf 'Ef. ~b,r-r~ ~~rl?l'if 6. ~~ifi'T~il~UI (q1~q"cfi/~ /~r.f /~cf) cfi. qJJ.fif>li!'m' -ill~~ ~ ' "&. lf. arrar.nm (!I om-fl) 'ET. ~31cllif'~ fitft)' ~ s'. ~~- 'tr. ~3'llfll- tJ'. 'itffra~~~ ~ . tilllf /~~/!ff Qtil~~~l'if [STFT III—'^ 3 : 4] «TRcT TFsm ; 15 7 oH a ^ ^ i o i M d # l Vfrto^" 3OTU15! (♦mk J^f) Pra^- TTTpT 5-10 OT5T 10-15 15-20 •Hlol 20-25 WeT 25-30 • H I S J l ' l o t » l , 3TT3RT, ^>h£, 3ftr3l«-*( « J I <3 <s*S d h d " <SI *5, 3irfir J3. •T. «-qn-W®T^ TJ. 9TT<ft 9>T ^snfr 5. yrfl'^'i attrsrr^TflMicMjfl »T. 3l«-<J stlrl^cll3lt ol*l «fl*ll \ W S r z i v , f & f H s = s r ^ r t r t 3lifc* cReT o <jf tARci f«h*ii oiicii 3s<Wci 'jll»i<*>il) y+riiti«t’ <<aKi y<;M ^>T *i$ f? ( Wole I Jta+A'ti I 2T5noT ^FrTTW) s<-t-ciI*J«t»’ (PFHT8TT I 3(*ji 5>T frRTRT (tlU td c ^ 1 ^ # rp rT re T T /3 h i* V T f5 R n 5 r,^ m R T re v ^ 3 T ? n r ?t) (sfrf^cT % ^RxTTWT, 'Tfif y fd ifl+ ^3TeT*T ?t) 15 I 1 ~c#;'I'~ ~ "t~'l•-' ~~(nvff) m;Jri ~ 'fffiJ:.ri 5-10 10-15 15-20 20-25 m'\lf 25-30 mtir lITN ~ lmf ~I\'!' cf;. ffl'3r.f, 31Ta'ra, ~t ~ ~ ~1tiwri~~ ri, 3q~~f11~13'l ~ ~- firffl~ri ,rr. nm=t.<fllrt 'ET. ~Tllftifilri S'. -,;ft-lit~ 3f""1' ~ r,n ~ ~- ~ ~- ~qfi!tQcn"]rr tt 1'ml- ~. ~ lnralif ~ 16 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— S ec. 4 ] 3 ^ 2^HT 3qoT®y d l ^ l ^ l 3TT?JTftcT f? 3FTT^ # ^W cTT3# % WTt A 'FW ^TR TT3TJJT3ttTfW 9971Tf^T<£)■[! 41<HI <^T oR'TcT ^ f ^ J c c f r ^ T ^ 31ltlK ^TT .icHlci ,3H’4 cIt 1 $Nll fS>oH i _____________________ ________________________ i. (T F c r r a ^ F ^ n w / 3i^ ii 5»r f*r?n»r) <s 2. (UTHT^^^FHTSTT) (tfrfJra c?iflB lrp x m n /3 m ^ 5 F T f» R n » T ,iifir y fH ig ^ '^ a n rir ?V) (41f*-lci c*y l^d ?T 3W T , *tfcl y«-rilc(<*> ^ 3T5PT 3 R 3 M - ST - ^ T H i ^ c T 3 c T C O l.ftftlfttl: 1. uflo*i 3ia*-*if jtiq-ir / *rai aftdrffcr / ^di tediffcn/ ^<3i «n{l^4rreit *» *mr/ ?n2foprraiv«rtfc ^mr/qftenrfcars qr-darffiffia t ^s/ ^qitii«^lcTl 1 2. ^1 oi Wei % oftro-/ 3ftr f5rt?r/^?Rr 3. ofrf^m^r 5TH5T / JRt^nr / 3uf 4. Mlfolifl «ll*i 3TW 5. 3ftcKfe*?frOTtfrfeHj ufa«4HigiT ltJ<UU| 6. ^n^nftofrf^r^Hca’rattrn^ 9tt oft snfrfc* on# 3ftr3r^q-^nft 5ii^r^?m??raT TOf jjt? 7. <Krt qTra^fl %««ficf4T fSur 8. *^J13?T14 ywrftd $ i. if ■PTH 3TTVR <TT / ii. afftlfT'TT iii. ^ o)c %" 3fTtnr 16 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III-SEC. 4] Sf fd 14¥ tJTJ<fi: .j•H)cfc:1 \?i~1f(~f ~ ~ ~('fttr ~ 7f$ "11crlcfil{) q'{ 3TTt.llfur ~ ~ x9R ~ ~~.3TT ~ 6fR ~ ,tt-8$1I.Q I df<TT ~ 3fR ~cfffi ~~~-fr ~ ~ ~ cf ~ mm ~ 3fltm 9"{ ~ x9R 39.Qcfc-1 ~ .., ~ : ____ _ 1. ,~~, 3Pl~ ctil f.llrr--n (~ ~cli~. lrft lilfi'ild'lfi d 3f(il7T 8') 3r.l1IT1T - "ET - c;1-fc1. fa c1 3 c-q ,a .:) 1. ~1q;1~tr: 1. ~3t~, nq.r / ~r 31fh1~c1 / ~ar~a,~ct/ ~ar •ncfl~rnre,~<Wffl'f/ •rren~11:~~ ffl'f/ ~~~ ~lla~~- t ~ I ~lllf.l~ I 2. ~i#i'l·~~t ~I~~ Jth-f.nhr/ inr.r 3. ~~f{RJT ~/ffl.cllf/:JW 4. qfflnft -l:ffflqs1ft,r ~~~ifllf~ ffl'f 5. ~ Jth-~ ~cA1-~ filnl· 'ilfclililcll cfiT ~ 6. ~mft~~cr~ 3th-~ ifiT ~ ~ ri~ ~ ~~mft ~~<tl&ifll<II -r-rrt? 7. ¥~iP@Tt1';-~~ ~ljl~~fi:tv lfd~t, 8. iRT3c=q"f~ 'il++il~cl *. I. ~-3'TtfR~ I ii. ~~3'TtfR~ iii. Q-;tt -1:r ff! qsfft'1 ~ 3'TtfR ~ . I I I — * 3 ^ 4 ] < ’ TRcT ^TT 17 tr ^ g /a « b m i x i g^rer f / f f a # /? w -3 T i^ £ f a 3 ? q T C f ^ r c f a r s^ r t ^ r ^ (? cfi? S4't-cHIctct-» % fpflj (?, Q'H'tii 3TTSJR 3 ? f a CiciKI Vl-J-dd o1l<r|<t>l£l f? al-HI f a f a 3H< c^cS (? 2f / gt®fw t f a f^Fr q t W r # R m t o r # t *jf w o t q fr f r f £ w f r r £r ^ f^|i|<H'l 3tlT ?lcfl, ^Mcl^irl, sili^l'4<H yfcl«ll5dl3lt <T f^f^o-trT oft pTRT (?, ? l l (j ferfa:_______________ __________________________________ /g ^ M #T R H T W ) . 2 oTJT y<-rii<5«t> y o )i /^«M ’M^’d/c»pii<H 3ftrifrJTRJcft^>ff^PPlftsr3f>t<-«n«t>K »i^1 4»<cii : # /3'«bi^'-H/<iHM 3ftr ^mn^fat R w ri^ r * *mr tf q i f a A _________________________________________________ 3T^Rft ft^ sr #r anroTT (m f& tft &t x m w f jy t f a r Jm r) <ft o x (^TRTTW '^TTW T / 3P |^ 9>T fr R lR ] (trf^cT s zr f ar % / 3i<ii ?>t f»i^n»T, ^rfcT v H T ra v ^ 3 i« < i ?t) oTJT TRfTeTt% old l«) # k*«h \n-ciiti«T» % Biwldl 3t<rAi cJjfacT ■3TT 5T?T olcim/fl+rllJfR’ ^ •M ld + / «flft-ld <^lfacT oqi-ii -*-*4iwfl*i m#n <Af ff yfd id y M ^ fa c R ^ i t o fco r arar fe^rr ^rar ^ 3 fa JT ^ r?m f:r3'3TT7rzTTB'. O *3 1. ______________________ (si-t-ciid^K / 3PT& 5ST f^TT5T) 2. (trf^cT c 2 r f ^ % j f r a m / 3 i ^ ^ 1 ^ n * r , 3 i f i f vFc=rTav*3Tenr ?t) 'IW"<f cfiT (1"1'PI : 3lmtffiUT ~ I '6~ ~t1q, c_Qt,tt ~~1fvic1 ~ ~/6~tf /pn,ra,cr~~rn~ 1t14'>1fH1 At!Pm" c!qRT ~ 1T"$" ' ..,..,..,..,.= ~ lt ~ ,....,1,lf,....,c1T::II a=cfi .t ~ ,j~ <Jifct ~. ~ .3mm" ~ ~ ~ -:illcrlcf,lfl 't ~ ~ ~ ~ cl~ -Jf / P, ~ cfi-ra t ~ fa"8" qffi;m'r ~ ~4'il~~I ~ t cl~ ~falclcfi ~ qft cITT° ~ ~ <fr 1f$" "51t1'1 " ~Jrt-{~ra'i. ~. i;ft~~f8aMc1IJfl" if Fcl~~~. ~ ~ t, ~llf11<'1 ~ ~ " ~ : ----- If ~ ~l~,R/~~rc;f ~ Gl~J.llcf;cTI ~T ~ ffltr ~ ~ (. # ~ ----------- ~ ~ ~ 3r.jllT{ (riffi;nft ifiT' ;rm- qr~ ;;rwJ ~ ,-mr ~ t 17 (>,ifriidcfi~ / ~ it>T ffnl'lil') ~ ~clt ~ # ~ Qfd,acfi .-, 3filllar ~ ~n ~ ~ ~~ .,.fd,aifi/ 1'1~cr ~ ~ ftilaft,q HllllT ~ f 1. ~ifi 8fdlWH / 3f1@" cfiT F.i111if) 2. ------- ~ c~clt'~/~cfiT~JPI',~ 'lfdldifi~mf1f ~ 18 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— Se c. 4] INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY NOTIFICATION Hyderabad, the 16th February, 2013 Insurance Regulatory and Development Authority (Standard Proposal Form for Life Insurance) Regulations, 2013 F. No. IRDA/Reg./10/68/2013.— In exercise ofthe powers conferred by Sections 14 (2) (b) oflR D A Act, 1999 (Act 41 o f 1999) and 114 (A ) (zc) and (zd) ofthe Insurance Act, 1938 (4 o f 1938), the Authority, in consultation with the Insurance Advisory committee, hereby makes the following regulations, namely :— Chapter I: Introductory 1. Short title and commencement (1). These regulations may be called the IRDA Regulations for Standard Proposal Form for Life Insurance, 2013. (2). They shall come into force on the date o f their publication in the official gazette. 2. Definitions In these regulations, unless the context otherwise requires, (1). ‘Act’ means the Insurance A ct, 1938 (4 o f 1938) (2). ‘Recommendation’ means advice provided by an agent or bancassurance or broker or an insurer where no agent or broker is involved, to an individual consumer that results in a purchase o f a life insurance policy in accordance with that advice. (3). ‘Suitability’ means a determination based on information provided in the standard proposal form that, based upon a particular prospect’s risk profile, financial situation, and investment objectives, a product is appropriate for that prospect.. (4). ‘Suitability information’ means information that is reasonably appropriate to determine the suitability o f a recommendation as provided for in the standard proposal form. (5). ‘Standard Proposal Form’ means Standard Proposal form format as attached to these Regulations as Annexure A consisting o f four parts, namely (A). Details o f the prospect (B). Specialized/Additional information. (C). Suitability Analysis (D). Recommendation, apart from the standard declarations to which no additions or deletions shall be made, where Section A and D are standard and mandatory, Section B may be modified as required and Section D is standard and highly recommended or such form as may be prescribed by the Authority from time to time. (6). All words and expressions used herein and not defined but defined in the Insurance Act, 1938 (4 o f 1938), or in the Insurance Regulatory and Development Authority Act, 1999 (41 o f 1999), or in any Rules or Regulations made thereunder, shall have the meanings respectively assigned to them in those Acts or Rules or Regulations. 3. Objective The Objective o f these Regulations is to provide for a standard proposal form for individual policies in Life Insurance that has an inbuilt flexibility for seeking additional / specialized information that is product specific or specific to a particular risk category, with a view to ensuring that it takes into consideration all relevant questions that are required to understand the need for a particular product and make a recommendation to the prospect bringing in transparency and thereby protecting the prospect’s interests. 4. Complementarity These regulations are complementary to the provisions relating to the proposal form provided for under the law, rules and regulations, in particular Section 45 and 51 o f the Insurance Act, 1938 Regulations 7 (d) and 4 o f the IRDA Regulations for protection o f Policyholders’ Interests, 2002 and Rule 12 o f the Insurance Rules, 1939. 18 THE GAZETTE OF INDIA : EXTRAORDINARY INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY NOTIFICATION Hyderabad, the 16th February, 2013 [PART IlJ-SEC. 4] Insurance Regulatory and Development Authority (Standard Proposal Form for Life Insurance) Regulations, 2013 F. No. IRDA/Reg./10/68/2013.-ln exercise of the powers conferred by Sections 14 (2) (b) ofIRDAAct, 1999 (Act 41 of 1999) and 114 (A) (zc) and (zd) of the Insurance Act, 1938 ( 4 of 1938), the Authority, in consultation with the Insurance Advisory committee, hereby makes the following regulations, namely:- Chapter I: Introductory 1. Short title and commencement ( 1 ). These regulations may be cal led the IRDA Regulations for Standard Proposal Form for Life Insurance, 2013. (2). They shall come into force on the date of their publication in the official gazette. 2. Definitions In these regulations, unless the context otherwise requires, ( 1 ). 'Act' means the Insurance Act , 1938 ( 4 of 1938) (2). 'Recommendation' means advice provided by an agent or bancassurance or broker or an insurer where no agent or broker is involved, to an individual consumer that results in a purchase of a life insurance policy in accordance with that advice. (3). 'Suitability' means a determination based on information provided in the standard proposal form that, based upon a particular prospect's risk profile, financial situation, and investment objectives, a product is appropriate for that prospect.. (4). 'Suitability information' means information that is reasonably appropriate to determine the suitability of a recommendation as provided for in the standard proposal form. (5). 'Standard Proposal Form' means Standard Proposal form format as attached to these Regulations as Annexure A consisting of four parts, namely (A). Details of the prospect (B). Specialized/Additional information. (C). Suitability Analysis (D). Recommendation, apart from the standard declarations to which no additions or deletions shall be made, where Section A and D are standard and mandatory, Section B may be modified as required and Section Dis standard and highly recommended or such form as may be prescribed by the ,Authority from time to time. (6). All words and expressions used herein and not defined but defined in the Insurance Act, 1938 (4 of 1938), or in the Insurance Regulatory and Development Authority Act, I 999 ( 41 of I 999), or in any Rules or Regulations made thereunder, shall have the meanings respectively assigned to them in those Acts or Rules or Regulations. 3. Objective The Objective of these Regulations is to provide for a standard proposal form for individual policies in Life Insurance that has an inbuilt flexibility for seeking additional / specialized information that is product specific or specific to a particular risk category, with a view to ensuring that it takes into consideration all relevant questions that are required to understand the need for a particular product and make a recommendation to the prospect bringing in transparency and thereby protecting the prospect's interests. 4. Complementarity These regulations are complementary to the provisions relating to the proposal form provided for under the law, rules and regulations, in particular Section 45 and 51 ofthe Insurance Act, 1938 ,Regulations 7 (d) and 4 of the IRDA Regulations for protection of Policyholders' Interests, 2002 and Rule 12 of the Insurance Rules, I 939. [*TFT III— 4] mcT tftot : ararmrtrr 19 Chapter II: Obligations 5. Applicability and Scope (1). These Regulations apply to all individual policies issued by life insurance companies, irrespective o f the segment and type o f product. (2). The obligations under these Regulations apply to Insurers and Intermediaries as defined therein. 6. Standard Proposal Form (1). It shall be mandatory for all life insurance companies to adopt the Standard Proposal Form. (2). A separate form is to be collected for each individual life proposed. 7. Determination of Suitability: (1). An Insurer or Agent or Bancassurance or Broker or the insurer’s employees where direct sales are involved, shall make reasonable efforts to obtain a consumer’ s ‘ suitability information’ prior to making a recommendation. (2). Based on the suitability o f information gathered from the prospect, the Insurer or Agent or Bancassurance or Broker or the insurer’s employees where direct sales are involved, must have reasonable grounds to believe that the product being recommended to the prospect is suitable for him / her. (3). In recommending the purchase o f a life insurance product, the Insurer or Agent or Bancassurance or Broker or the insurer’s employees where direct sales are involved, shall ensure the following: (a). The prospect has been informed o f the products available and the details o f the features o f the i particular product being recommended. This would include but not be limited to the benefits, various charges such as surrender charge, administration charge and all other charges as applicable, market risks etc. - in other words all relevant features o f the product necessary for the prospect to make an informed decision. (b). The Insurer or Agent or Bancassurance or Broker or the insurer’s employee where direct sale is involved, believes that a particular product would suit the needs o f the prospect. 8. Insurers to establish supervisory procedures: (1). An insurer shall establish a supervision system that is designed to achieve compliance with these guidelines including but not limited to the following: (a). The insurer shall maintain procedures to inform Agents, Bancassurance, Brokers or and its employees where direct sales are involved, o f the requirements o f these guidelines and o f the need to collect the standard proposal form/s for the purpose o f suitability analysis and making a Recommendation. (b). The Agents, Bancassurance, Brokers and its employees where direct sales are involved, shall be adequately trained to determine suitability. (c). The insurer shall maintain procedures for review o f each recommendation prior to issuance o f a product that is designated to ensure that there is a reasonable basis to determine that a recommendation is suitable. Such review procedures shall include a screening system for the purpose o f identifying selected sale transactions for a detailed review. Such review may be accomplished electronically or through other means including but not limited to physical review. (d ). The insurer shall maintain procedures to detect recommendations that are not suitable. This may include, but not limited to confirmation o f suitability information, systematic consumer surveys, verification calls or interviews, confirmation letters and programs o f internal monitoring. An insurer may apply sampling procedures for confirming suitability information after issuance or delivery o f the product. [<qTTT IIl-19Us 4] Chapter II: Obligations 5. Applicability and Scope {l). These Regulations apply to all individual policies issued by life insurance companies, irrespective of the segment and type of product. (2). The obligations under these Regulations apply to Insurers and Intermediaries as defined therein. 6. Standard Proposal Form (l ). It shall be mandatory for all life insurance companies to adopt the Standard Proposal Form. (2). A separate form is to be collected for each individual life proposed. 7. Determination of Suitability: (l ). An Insurer or Agent or Bancassurance or Broker or the insurer's employees where direct sales are involved, shall make reasonable efforts to obtain a consumer's 'suitability information' prior to making a recommendation. (2). Based on the suitability of information gathered from the prospect, the Insurer or Agent or Bancassurance or Broker or the insurer's employees where direct sales are involved, must have reasonable grounds to believe that the product being recommended to the prospect is suitable for him / her. (3). In recommending the purchase of a life insurance product, the Insurer or Agent or Bancassurance or Broker or the insurer's employees where direct sales are involved, shall ensure the following: (a). The prospect has been informed of the products available and the details of the features of the particular product being recommended. This would include but not be limited to the benefits, various charges such as surrender charge, administration charge and all other charges as applicable, market risks etc. - in other words all relevant features of the product necessary for the prospect to make an informed decision. (b). The Insurer or Agent or Bancassurance or Broker or the insurer's employee where direct sale is involved, believes that a particular product would suit the needs of the prospect. 8. Insurers to establish supervisory procedures: (I). An insurer shall establish a supervision system that is designed to achieve compliance with these guidelines including but not limited to the following: (a). The insurer shall maintain procedures to inform Agents, Bancassurance, Brokers or and its employees where direct sales are involved, of the requirements of these guidelines and of the need to collect the standard proposal form/s for the purpose of suitability analysis and making a Recommendation. (b). The Agents, Bancassurance, Brokers and its employees where direct sales are involved, shall be adequately trained to determine suitability. ( c ). The insurer shall maintain procedures for review of each recommendation prior to issuance of a product that is designated to ensure that there is a reasonable basis to determine that a recommendation is suitable. Such review procedures shall include a screening system for the purpose of identifying selected sale transactions for a detailed review. Such review may be accomplished electronically or through other means including but not limited to physical review. (d). The insurer shall maintain procedures to detect recommendations that are not suitable. This may include, but not limited to confirmation of suitability information, systematic consumer surveys, verification calls or interviews, confirmation letters and programs of internal monitoring. An insurer may apply sampling procedures for confirming suitability information after issuance or delivery of the product. 19 20 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— Sec. 4] 9. Record Keeping: (1). Insurers, Agents, Bancassurance or Brokers shall maintain and make available to the Authority for inspection or whenever called for by the Authority, records o f information collected from the prospect and other information used in making the recommendations that were the basis for insurance transactions for five years after the insurance transaction is completed by the insurer when required by the Authority. (2). The records may be maintained in physical or electronic form or any process that accurately reproduces the actual document and can stand legal scrutiny. 10. Training Agents , Bancassurance and the insurer’s employees where direct sales are involved shall be adequately trained on seeking information for suitability analysis. Brokers shall also be given the necessary inputs for sale o f the products o f a particular insurer. Further, insurer shall ensure that Agents, Bancassurance, Brokers and direct sales personnel are given thorough training regarding the various specific products of the insurance company. Chapter III: Implementation 11. Compliance Date The date of implementation o f the obligations under Regulations 5,6,7,8,9 & 10 shall be from the date following six calendar months from the date o f publication o f these Regulations in the official gazette. Chapter IV: Miscellaneous 12. Power to remove difficulties If any difficulty arises in giving effect to the provisions o f these Regulations, the Authority may, by order, make such provisions or give such directions not inconsistent with the provisions o f these Regulations as may appear to be necessary or expedient for the removal o f the difficulty. J. HARI NARAYAN, Chairman [ADVT. 111/4/161/12/Exty.] ANNEXURE A STANDARD PROPOSAL FORM FOR LIFE INSURANCE Name of the Insurance Company : Servicing Branch Name : Affix latest passport size Complete Address of Servicing Branch photograph Agency / Broker Name and contact details : here License No. & Validity Details : Name of the Product Sum Assured 20 THE GAZETTE OF INDIA : EXTRAORDINARY [PART 111- SEC. 4] 9. Record Keeping: (I). Insurers, Agents, Bancassurance or Brokers shall maintain and make available to the Authority for inspection or whenever called for by the Authority, records of information collected from the prospect and other information used in making the recommendations that were the basis for insurance transactions for five years after the insurance transaction is completed by the insurer when required by the Authority. (2). The records may be maintained in physical or electronic form or any process that accurately reproduces the actual document and can stand legal scrutiny. 10. Training Agents , Bancassurance and the insurer's employees where direct sales are involved shall be adequately trained on seeking information for suitability analysis. Brokers shall also be given the necessary inputs for sale of the products of a particular insurer. Further, insurer shall ensure that Agents, Bancassurance, Brokers and direct sales personnel are given thorough training regarding the various specific products of the insurance company. Chapter III: Implementation 11. Compliance Date The date of implementation of the obligations under Regulations 5,6,7,8,9 & 10 shall be from the date following six calendar months from the date of publication of these Regulations in the official gazette. Chapter IV: Miscellaneous 12. Power to remove difficulties Jfany difficulty arises in giving effect to the provisions of these Regulations, the Authority may, by order, make such provisions or give such directions not inconsistent with the provisions of these Regulations as may appear to be necessary or expedient for the removal of the difficulty. J. HARi NARAYAN, Chainnan [ADVT. III/4/161/12/Exty.] ANNEXUREA STANDARD PROPOSAL FORM FOR LIFE INSURANCE Name of the Insurance Company Servicing Branch Name Complete Address of Servicing Branch Agency / Broker Name and contact details License No. & Validity Details Affix latest passport size photograph here I Name of the Product Sum Assured I I [■RFT III—73^ 4] WT7 : sraTKTFFF 21 Term of the Product Premium Paying Term Premium Payment Mode (One time/Annual/Half Yearly/Quarterly etc.) (Signature of Proposer) (Signature of Agent/Broker/Bancassurance) (Signature of Insurer)* *At the time of acceptance of proposal Instructions for Proposer: Please follow these carefully 1. It is necessary for the proposer to fill up this proposal form himself/herself and not allow an intermediary or any third party to do it. However, in case the proposer is not in a position to do so or the details are filled in by the proposer in vernacular, he/she must ensure that the details filled in are read out to him/her and that they are understood by him/her. He/she must make a declaration to this effect as indicated in Section D of this form. 2. Please read all the questions carefully and fill up the details truthfully. 3. Please ensure that you affix your signatures in all the places as required. In certain places more than one signature is required. This is in your own interest 4. Wherever the intermediary (Agent/Bancassurance/Broker) is required to sign, please ensure that the same has been done by him/her. 5. This form contains 4 sections namely Section A: Contains the Details of Proposer which is mandatory, Section B: Contains Specialised/Additional Information which may vary based on the product, Section C: Contains Suitability Analysis which is highly recommended and Section D: Product Proposed which is mandatory. 6. For proposer and each life assured, separate forms to be submitted. 7. Signature/ of life assured and/or proposer sought twice in his/her interest. Instructions to Intermediary (Agent/Bancassurance/Broker): Please follow these carefully 1. It is highly recommended that the proposer is advised by you to give information required for Suitability Analysis as per Section C of the form, in his/her own interest. 2. Please ensure that the product recommended suits the needs o f the proposer. 3. Do not fill up the proposal form or any column of the form on behalf of the proposer even if requested to do so. 4. Please ensure that you affix your signatures wherever required in the form. 5. Please ensure that for proposer and each life assured, separate forms are collected. [ 'llflT IIl- 19fUs 4 ] 21 Term of the Product Premium Paying Term Premium Payment Mode (One time/ Annual/Half Yearly/Quarterly etc.} (Signature of Proposer) (Signature of Agent/Broker /Bancassurance) (Signature of Insurer)* *At the time of acceptance of proposal ,-------------------------------------------. Instructions for Proposer: Please follow these carefully 1. It is necessary for the proposer to fill up this proposal form himself /herself and not allow an intermediary or any third party to do it. However, in case the proposer is not in a position to do so or the details are filled in by the proposer in vernacular, he/she must ensure that the details filled in are read out to him/her and that they are understood by him/her. He/she must make a declaration to this effect as indicated in Section D of this form. 2. Please read all the questions carefully and fill up the details truthfully. 3. Please ensure that you affix your signatures in all the places as required. In certain places more than one signature is required. This is in your own interest 4. Wherever the intermediary (Agent/Bancassurance/Broker) is required to sign, please ensure that the same has been done by him/her. 5. This form contains 4 sections namely Section A: Contains the Details of Proposer which is mandatory, Section B: Contains Specialised/ Additional Information which may vary based on the product, Section C: Contains Suitability Analysis which is highly recommended and Section D: Product Proposed which is mandatory. 6. For proposer and each life assured, separate forms to be submitted. 7. Signature/ of life assured and/or proposer sought twice in his/her interest. Instructions to Intermediary (Agent/Bancassurance/Broker): Please follow these carefully I 1. It is highly recommended that the proposer is advised by you to give information required for l Suitability Analysis as per Section C of the form, in his/her own interest. I 2. Please ensure that the product recommended suits the needs of the proposer. 3. Do not fill up the proposal form or any column of the form on behalf of the proposer even if requested to do so. 4. Please ensure that you affix your signatures wherever required in the form. 5. Please ensure that for proposer and each life assured, separate forms are collected. 22 THE GAZETTE OF INDIA : EXTRAORDINARY [P ar t III— Sec. 4] SECTION A: DETAILS OF PROPOSER and/or LIFE ASSURED (Mandatory) l. Personal Details a. Name b. Spouse’s Name c. Father’s Name d. Mother’s Name e. Gender f. Date of birth g. Age Proof h. Identification marks i. Address for Communication j. Permanent Address k. Address Proof (Electricity Bill/ Telephone Bill/Ration Card)* 1. Telephone ( Landline/Mobile) m. E-mail id n. Marital status o. Nationality p. Education Qualifications q. Habits impacting health adversely (i). Smoking/other tobacco related habits Yes/No a) If Yes, whether occasionally or frequently (ii). Consuming Alcohol Yes/No b) If Yes, whether occasionally or frequently (iii). Drug Abuse Yes/No r. Habits having a positive impact on health Yes/No (i). If Yes, specify details (* Any one to be submitted) 2. Identification Proof * a. PAN Number b. Aadhaar Number c. Ration Card/Driving License/ Passport Number (* Any one to be submitted) 22 I 1. THE GAZETTE OF INDIA : EXTRAORDINARY [PART III- SEC. 4] SECTION A: DETAILS OF PROPOSER and/or LIFE ASSURED (Mandatory) Personal Details - a. Name - b. Spouse's Name c. Father's Name d. Mother's Name e. Gender -- f. Date of birth g. Age Proof h. Identification marks i. Address for Communication r j. Permanent Address k. Address Proof (Electricity Bill/ Telephone Bill/Ration Card}* I. Telephone ( Landline/Mobile) m. E-mail id n. Marital status 0. Nationality p. Education Qualifications q. Habits impacting health adversely (i). Smoking/other tobacco related Yes/No habits a) If Yes, whether occasionally or frequently (ii). Consuming Alcohol Yes/No b) If Yes, whether occasionally or frequently (iii). Drug Abuse Yes/No r. Habits having a positive impact on Yes/No health (i). If Yes, specify details (*Anyone to be submitted} 2. Identification Proof * a. PAN Number b. Aadhaar Number c. Ration Card/ Driving Lice,nse/ Passport Number ('" Any one to be submitted) I 24 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— Sec. 4 ] c. Account type - d. Bank Name and Branch - 8. Details o f Nom inee & Appointee* Nominee Appointee a. Name b. Date of Birth c. Relationship d. Address e. Percentage of entitlement *where Nominee is a minor, Appointee details also to be furnished 9. Existing Insurance Name of Member (whether proposer or covered person) Details of premium being paid (in RupeesJ Name of Member (whether proposer or covered person)__ Details of premium being paid (in Rupees) a. Life b. Health c. Unit Linked Insurance Policy d. Pension Policy e. Other ( to specify) 10. What is the purpose of your opting for this policy? (Sections 41 and 45 to be reproduced by insurer) Declaration: I/We hereby declare, on my behalf and on behalf of all persons 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 of my knowledge and that I/W e am /are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of the insurance policy and that the policy is subject to Board approved underwriting policy of the insurance company and the policy will come into force only after full receipt of the premium chargeable. I/We further declare that I/we will notify in writing any change occurring in the occupation, financial health or general health of the life to be assured/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 assured/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 office to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and claim settlement. I/We authorize the company to share information pertaining to my proposal including the medical records with any Governmental and/or Regulatory authority. Further, the information may be shared for the sole purpose of proposal underwriting and claims settlement. 24 THE GAZETTE OF INDIA : EXTRAORDINARY c. Account type d. Bank Name and Branch . 8. Detail4i of Nominee & Appointee* Nominee a. Name b. Date of Birth c. Relationship d. Address e. Percentage of entitlement •where Nominee is a minor, Appointee details also to be furnished 9. Existing Name of Member Details of premium Insurance (whether proposer being paid (in or covered person) Rupees) a. Life b. Health c. Unit Linked Insurance Policy d. Pension Policy e. Other ( to specify) 10. What is the purpose of your opting for this policy? (Sections 41 and 45 to be reproduced by insurer) Declaration: Appointee Name of Member (whether proposer or covered person) ' [PART III- SEC. 4) Details of premium being paid (in Rupees) I/We hereby declare, on my behalf and on behalf of all persons 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 of my knowledge and that I/We am/are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of the insurance policy and that the policy is subject to Board approved underwriting policy of the insurance company and the policy will come into force only after full receipt of the premium chargeable. I/We further declare that I/we will notify in writing any change occurring in the occupation, financial health or general health of the life to be assured/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 assured/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 office to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and claim settlement. I/We authorize the company to share information pertaining to my proposal including the medical records with any Governmental and/or Regulatory authority. Further, the information may be shared for the sole purpose of proposal underwriting and claims settlement. [■RFT III— 4] ■rtct : srar^H 0! 23 3. Family details a. Number of dependants b. Details of dependants 1 2 3 4 5 c. Name d. Male/Female e. Relationship f. Age g. Date of Birth h. Occupation i. Whether financially dependent 4. If employed - Employment details a. Occupation b. Nature of Work c. Length of service d. Annual income {in Rupees) e. Details of Income proof submitted f. Whether covered under pension scheme g. Normal retirement age 5. If self-employed - Details a. Occupation b. Nature of Work c. Projected active working life d. Annual income (in Rupees) e. If labour - Number of working days 6. Pension Details, if any, if not employed/self-employed a. Employer's Scheme/Insurance b. Personal contribution/Premium c. Retirement age d. Anticipated value 7. Bank details a. Do you have a bank account? Yes/No b. If yes, Account No 23 3. Family details a. Number of dependants b. Details of dependants 1 2 3 4 5 c. Name - d. Male/Female e. Relationship f. Age g. Date of Birth h. Occupation i. Whether financially dependent I 4. If employed - Employment details a. Occupation b. Nature of Work c. Length of service d. Annual income (in Rupees) ' e. Details of Income proof submitted f. Whether covered under pension scheme g. Normal retirement age ,_ 5. If self-employed - Details a. Occupation b. Nature of Work c. Projected active working life d. Annual income (in Rupees) I e. lflabour - Number of working days 6. Pension Details, if any, if not employed/ self-employed a. Employer's Scheme/Insurance b. Personal contribution/Premium c. Retirement age d. Anticipated value . 7. Bank details a. Do you have a bank account? Yes/No b. If yes, Account No [•RPT III— 3 3 ^ 4 ] < ’TRcT 3TT XT5m : 25 Date: (Signature of Proposer/Thumb Impression) (Signature of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) SECTION B: SPECIALISED/ADDITIONAL INFORMATION l. Physical/Medical Information (Questionnaire)— for each covered person Height : Weight : a. Do you have any physical deformity/handicap/congenital defect/abnormality? YES/NO b. Are you currently undergoing/have undergone any tests, investigations, awaiting results of any tests, investigations or have you ever been advised to undergo any tests, investigations or surgery or been hospitalized for general checkup, observations, treatment or surgery? YES/NO c. Have you ever been treated or hospitalized for Cancer, Tumor, Cysts or any other growth? YES/NO d. Have you ever been referred to an Oncologist or Cancer hospital for any investigation or treatment? YES/NO e. Did you have any ailment/injury/accident requiring treatment/medication for more than a week? YES/NO f. Have you ever been absent from work for more than a week in last 2 years due to any illness? YES/NO g. Were you or your spouse ever tested for Hepatitis B or C, HIV/AIDS or any other sexually transmitted disease? YES/NO 1,54 6‘lr2~ 7 [ 'lll11 Ill- ~ 4] 25 Date: _____ _ (Signature of Proposer /Thumb Impression) (Signature of Proposer) 1. a. b. c. d. e. f. g. (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) SECTION B: SPECIALISED/ADDITIONAL INFORMATION Physical/Medical Information (Questionnaire)-for each covered person Height : Weight : Do you have any physical deformity /handicap/congenital defect/abnormality? YES/NO Are you currently undergoing/have undergone any tests, investigations, awaiting YES/NO results of any tests, investigations or have you ever been advised to undergo any tests, investigations or surgery or been hospitalized for general checkup, observations, treatment or surgery? Have you ever been treated or hospitalized for Cancer, Tumor, Cysts or any other YES/NO growth? Have you ever been referred to an Oncologist or Cancer hospital for any investigation or YES/NO treatment? Did you have any ailment/injury/accident requiring treatment/medication for more YES/NO than a week? Have you ever been absent from work for more than a week in last 2 years due to any YES/NO illness? Were you or your spouse ever tested for Hepatitis B or C, HIV/ AIDS or any other YES/NO sexually transmitted disease? -- 26 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— Sec. 4] h. Have you ever suffered Chest pain, Palpitation, Rheumatic fever, Heart Murmur, Heart attack, shortness of Breath or any other Heart related disorder? YES/NO i. Have you ever suffered symptoms/ailment relating to Kidney, Prostate, Hydrocele, And Urinary System? YES/NO j. Have you ever suffered Gastritis, Stomach or Duodenal Ulcer, Hernia, Jaundice, Fistula Piles or any other disease or disorders of the Gastrointestinal System? YES/NO k. Have you ever suffered Thyroid disorder or any other disease or disorder of the Endocrine system? YES/NO 1. Have you undergone/have been recommended to undergo Angioplasty, Bypass Surgery, Brain Surgery, Heart Valve Surgery, Aorta Surgery or Organ Transplant? YES/NO m. Have you ever suffered Diabetes/ High Blood Sugar? YES/NO n. Have you ever suffered High/Low Blood Pressure? YES/NO o. Have you ever suffered Disorders of Eye, Ear, Nose, Throat including defective sight, speech or hearing & discharge from ears? YES/NO p. Have you ever suffered ailments relating to Liver or reproductive System? YES/NO q. Have you ever suffered Symptoms/ailments relating to Brian, Depression? Mental/Psychiatric ailment, Multiple Sclerosis, Nervous System, Stroke, Paralysis, Parkinsonism or Epilepsy? YES/NO r. Have you ever suffered Asthma, Bronchitis, Blood spitting, Tuberculosis or other Respiratory disorders? YES/NO s. Have you ever suffered Anaemia, Blood or Blood related disorders? YES/NO t Have you ever suffered Musculoskeletal disorders such as Arthritis, Recurrent Back Pain, Slipped disc or any other disorder of Spine, Joints, Limbs or Leprosy? YES/NO u. Have you ever suffered any other illness or impairment not mentioned above? YES/NO 2. Details of Female Proposers /covered person a. Are you currently pregnant? YES/NO b. If yes, current months of pregnancy c. State age of first pregnancy d. Have you ever had any abortion, miscarriage or ectopic pregnancy? YES/NO e. Have you undergone any gynecological investigations, internal checkups, breast checks such as mammogram or biopsy? YES/NO f. Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, fallopian tubes, menstruation, birth delivery, complications during pregnancy or child delivery or a sexually transmitted disease? YES/NO / [Note: Insurers may ask appropriate questions based on particular product. The above questions are illustrative only.] 26 THE GAZETTE OF £NOIA : EXTRAORDrNARY [PART III- SEC. 4) ~ h. Have you ever suffered Chest pain, Palpitation, Rheumatic fever, Heart Murmur, Heart YES/NO attack, shortness of Breatli or any other Heart related disorder? i. Have you ever suffered symptoms/ailment relating to Kidney, Prostate, Hydrocele, And YES/NO Urinary System? j. Have you ever suffered Gastritis, Stomach or Duodenal Ulcer, Hernia, Jaundice, Fistula YES/NO Piles or any other disease or disorders of the Gastrointestinal System? k. Have you ever suffered Thyroid disorder or any other disease or disorder of the YES/NO Endocrine system? I. Have you undergone/have been recommended to undergo Angioplasty, Bypass Surgery, YES/NO Brain Surgery, Heart Valve Surgery, Aorta Surgery or Organ Transplant? m. Have you ever suffered Diabetes/ High Blood Sugar? YES/NO n. Have you ever suffered High/Low Blood Pressure? YES/NO o. Have you ever suffered Disorders of Eye, Ear, Nose, Throat including defective sight, YES/NO speech or hearing & discharge from ears? . p. Have you ever suffered ailments relating to Liver or reproductive System? YES/NO q. Have you ever suffered Symptoms/ailments relating to Brian, Depression? YES/NO Mental/Psychiatric ailment, Multiple Sclerosis, Nervous System, Stroke, Paralysis, Parkinsonism or Epilepsy? r. Have you ever suffered Asthma, Bronchitis, Blood spitting, Tuberculosis or other YES/NO Respiratory disorders? s. Have you ever suffered Anaemia, Blood or Blood related disorders? YES/NO t. Have you ever suffered Musculoskeletal disorders such as Arthritis, Recurrent Back YES/NO Pain, Slipped disc or any other disorder of Spine, Joints, Limbs or Leprosy? u. Have you ever suffered any other illness or impairment not mentioned above? YES/NO I 2. Details of Female Proposers /covered person a. Are you currently pregnant? YES/NO b. If yes, current months of pregnancy c. State age of first pregnancy d. Have you ever had any abortion, miscarriage or ectopic pregnancy? YES/NO e. Have you undergone any gynecological investigations, internal checkups, breast checks YES/NO such as mammogram or biopsy? f. Have you ever consulted a doctor because of an irregularity at the breast, vagina, YES/NO uterus, ovary, fallopian tubes, menstruation, birth delivery, complications during pregnancy or child delivery or a sexually transmitted disease? [Note: Insurers may ask appropriate questions based on particular product. The above questions are illustrative only.) [SIFT 111—^ 5 4 ] < IT5PTW : 3T?TT^TTT,Tr 27 Declaration: I/We hereby declare, on my behalf and on behalf of all persons 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 of my knowledge and that I/W e am /are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of the insurance policy and that the policy is subject to Board approved underwriting policy of the insurance company and the policy will come into force only after full receipt of the premium chargeable. I/W e further declare that I/we will notify in writing any change occurring in the occupation, financial health or general health of the life to be assured/proposer after the proposal has been submitted but before communication of the risk acceptance by the company. I/W e 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 assured/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 office to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and claim settlement. I/We authorize the company to share information pertaining to my proposal including the medical records with any Governmental and/or Regulatory authority. Further, the information may be shared for the sole purpose of proposal underwriting and claims settlement. Date:________________ I (Signature of Proposer/Thumb Impression) (Signature of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) [ 'l'.lfll Ill- ~ 4] Tl Declaration: I/We hereby declare, on my behalf and on behalf of all persons 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 of my knowledge and that I/We am/are authorized to propose on behalf of these other persons. I understand that the information provided by me will form the basis of the insurance policy and that the policy is subject to Board approved underwriting policy of the insurance company and the policy will come into force only after full receipt of the premium chargeable. I/We further declare that I/we will notify in writing any change occurring in the occupation, financial health or general health of the life to be assured/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 assured/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 office to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and claim settlement. I/We authorize the company to share information pertaining to my proposal including the medical records with any Governmental and/or Regulatory authority. Further, the information may be shared for the sole purpose of proposal underwriting and claims settlement. (Signature of Proposer /Thumb Impression) (Signature of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) 28 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— Sec. 4] SECTION C: SUITABILITY ANALYSIS (Highly recommended) 1. Affordable contribution— Current and projected (in Rupees) YEAR Last Year Current Year 5-10 Years 10-15 Years 15-20 Years 20-25 Years 25-30 Years a. Yearly b. Monthly 2. How do you project your work span? a. Number of Years 5 Years 10 Years 15 Years 20 Years 25 Years 30 Years b. Working span 3. Income/Expenditure --Current and projected (in Rupees) YEAR Last Year Current Year 5-10 Years 10-15 Years 15-20 Years 20-25 Years 25-30 Years a. Income b. Expenditure 4. Financial details a. Value of savings and assets (in Rupees) b. Details of liabilities c. Expected inheritance 1 5. Identified insurance needs (in Rupees) a. Life Insurance ( Death/Maturity) Desirable Sum Assured b. Health Insurance Desirable limit of coverage per annum c. Savings and Investment Planning Desirable returns per annum d. Pension planning Desirable pension per annum 28 THE GAZETTE OF INDIA : EXTRAORDINARY SECTION C: SUITABILITY ANALYSIS (Highly recommended) 1. Affordable contribution-Current and projected (in Rupees) YEAR Last Current 5-10 10-15 15-20 Year Year Years Years Years a. Yearly b. Monthly I I 2. How do you project your work span? a. Number of Years 5 Years 10 Years 15 Years 20 Years b. Working span 3. Income/Expenditure --Current and projected (in Rupees) YEAR Last Year Current 5-10 10-15 15-20 Year Years Years Years a. Income b. Expenditure . - ----- _____ _ .._____ 4. Financial details a. Value of savings and assets (in Rupees) b. Details of liabilities c. Expected inheritance I 5. Identified insurance needs (in Rupees) a. Life Insurance ( Death/Maturity) Desirable Sum Assured b. Health Insurance Desirable limit of coverage per annum c. Savings and Investment Planning Desirable returns per annum d. Pension planning I Desirable pension per annum [PART III-SEC. 4) 20-25 25-30 Years Years ZS Years 30 Years 20-25 25-30 Years Years • I I [«fPT III— 4 ] *TRcT W T3 : 3WI^r^T 29 6. Insurance Plan Details ( Traditional/ULIP/Pension/Health) a. Plan Name b. Premium Type c. Payment Mode d. Payment Method e. Premium Term f. Coverage Term g. Sum Assured (in Rupees) h. Benefits/Riders/Fund Allocation 7. Identified Life needs Projections per annum (in Rupees) ITEM/YEAR Last Year Current Year 5-10 Years 10-15 Years 15-20 Years 20-25 Years 25-30 Years a. Food, shelter, clothing and other living expenses such as transportation expenses, utilities etc b. Education expenses c. Health expenses d. Marriage expenses e. Vacations and other travel expenses f. Other commitments such as insurance premium, various contributions etc TOTAL It is declared that the above information has been provided by the proposer (Signature of Agent/Bancassurance/Broker) (Signature of Proposer)/Thumb Impression (Signature of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) [ '!WT Ill-~ 4] 'lmcl cfil ~ ,3'.f"ffi~ 6. Insurance Plan Details ( Traditional/ULIP /Pension/Health) I I I a. Plan Name I_ b. Premium Type ' - - - c. Payment Mode d. Payment Method - --~- e. Premium Term f. Coverage Term g. Sum Assured (in Rupees) h. Benefits/Riders/Fund Allocation 7. Identified Life needs Projections per annum (in Rupees) ITEM/YEAR Last Current 5-10 10-15 15-20 20-25 25-30 Year Year Years Years Years Years Years a. Food, shelter, clothing and other living expenses such as transportation expenses, utilities I etc - b. Education expenses - · ·- c. Health expenses d. Marriage expenses e. Vacations and other travel expenses f. Other commitments such as insurance premium, various contributions etc TOTAL ~ It is declared that the above information has been provided by the proposer (Signature of Agent/Bancassurance/Broker) (Signature of Proposer)/Thumb Impression (Signature of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) 30 THE GAZETTE OF INDIA : EXTRAORDINARY [P a r t III— Sec. 4] SECTION D: PRODUCT PROPOSED (Mandatory) 1. Recommendation: 1. Life stags Childhood/Young unmarried/Young married/ Young married with children/married with older children/post-family or pre­ retirement/ retirement 2. Protection needs Life & Health/Savings and Investment/Pension 3. Appetite for risk Low/Medium/High 4. Policy recommended, including name of insurer 5. Details of commitment for the current and future years 6. Whether all risk elements and details of charges to be incurred and all other obligations have been explained? 7. Why you think this policy is most suited for the proposer? 8. Whether product proposed is i. Based on need ii. Based on demand iii. Based on Agent recommendation Agent/Bancassurance/Broker's Certification: I /We hereby certify that I/we believe that the product/s recommended me/us above is suitable for the proposer, based on the information submitted by him/her, as recorded above. I/We declare that the policy recommended has been fully explained to the proposer, including about the terms and conditions, exclusions, premium commitments and various charges, as applicable. Dated:_________________ ____________________________________ {Signature of Agent/Bancassurance/Broker) (Signature of Insurer) Proposer's Acknowledgement: The above recommendation is based on the information provided by me. I have been explained about the features of the product and believe it would be suitable for me based on my insurance needs and financial objectives. Dated:_________________ ____________________ (Signature/Thumb Impression of Proposer) (Signature of Proposer) 30 THE GAZETTE OF INDIA : EXTRAORDINARY SECTION D: PRODUCT PROPOSED (Mandatory) [PART III- SEC. 4) r--- - ·--- I 1. Recommendation: I . 1. Life stage Childhood/Young unmarried/Young married/ Young married I with children/married with older children/post-family or pre- retirement/retirement e--· ------------ -- 2. Protection needs Life & Health/Savings and Investment/Pension 3. Appetite for risk Low /Medium/High 4. Policy recommended, including name of insurer 5. Details of commitment for the current and future years 6. Whether all risk elements and details of charges to be incurred and all other obligations have been explained? 7. Why you think this policy is most suited for the proposer? 7 8. Whether product proposed is i. Based on need ii. Based on demand iii. Based on Agent recommendation Agent/Bancassurance/Broker's Certification: I / We hereby certify that I/we believe that the product/s recommended me/us above is suitable for the proposer, based on the information submitted by him/her, as recorded above. I/We declare that the policy recommended has been fully explained to the proposer, including about the terms and conditions, exclusions, premium commitments and various charges, as applicable. Dated: ______ _ I (Signature of Agent/Bancassurance/Broker) (Signature of Insurer) Proposer's Acknowledgement: The above recommendation is based on the information provided by me. I have been explained about the features of the product and believe it would be suitable for me based on my insurance needs and financial objectives. Dated: ------- (Signature/Thumb Impression of Proposer) (Signature of Proposer) [*rm hi—igvg 4] < 31 (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) 2. Where the proposer does not accept the Recommendation of the Agent/Bancassurance/Broker and Insurer: I am not in agre for the policy n; I ement with the Recommendation of the Agent/Bancassurance/Broker and Insurer. I have opted imed fname of nolicv to be mentioned herei asDerm vwish. (Signature/Thumb Impression of Proposer) ( Signature /Thumb Impression of Life Assured, where different from Proposer) Where answers to the questions are filled in by a person other than the proposer or where the answers/ signature of the Proposer/Life Assured are in vernacular: The details in the proposal form have been read out and explained to me and I have understood the same. (Signature/Thumb Impression of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) Printed by the Manager, Government o f India Press, Ring Road, Mayapuri, N ew D elhi-110064 and Published by the Controller o f Publications, Delhi-110054. (Signature/Thumb Impression of Life Assured, if different from Proposer) I 2. Where the proposer does not accept the Recommendation of the A ent Bancassurance Broker and Insurer: (Signature of Life Assured, if different from Proposer) I am not in agreement with the Recommendation of the Agent/Bancassurance /Broker and Insurer. I have opted for the policy named ________ ___ (name of policy to be mentioned here) as per my wish. 31 (Signature/Thumb Impression of Proposer) ( Signature /Thumb Impression of Life Assured, where different from Proposer) Where answers to the questions are filled in by a person other than the proposer or where the answers/ signature of the Proposer/Life Assured are in vernacular: The details in the proposal form have been read out and explained to me and I have understood the same. (Signature/Thumb Impression of Proposer) (Signature/Thumb Impression of Life Assured, if different from Proposer) Printed by the Manager, Government of India Press, Ring Road, Mayapuri, New Delhi-I 10064 and Published by the Controller of Publications, Delhi-I I 0054.