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

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I {I f.!iJ-.lF.lfillo fctf.!I 4'1 ilolR!T ~ 31t1h, ' ~l:\lfdlqir11 1. milt:n ~ atlT 'llR1'lr (1). ~ fctf.!14;,./j q;I' ill"1l fctf.!141'1ifi 3ffi ~ ~ (;;frcr.r iftm ~ foN '1Ti,1I; 'll'f<1lq m) fctf.!14'1, 2013 ~om,~ 'Cjqil{T ;,rr,mr 1 ~ 2. qftiil'4iJ' (1). .,rltlf.h1., 'liT ~ iftm ~, 1938 [1938clil4) ~~I (2) ~q,1!\.( ifiT ~ 11<1; m >II il'ifil-t_!~~ m l;1'1Tof m 11<1' iftm ~ ~ ~' zj ~ m m lf<'1ffi ~ntffi;r al' ~, ~ ~ m.=r ~ ~ ~ cliT 3ltt ~ f<I;' 11<1' e<lr<ffi' ~ ~ ~ 11<1' ~ iftm ~ ifiT ~ ~ ~ q\'<0 11'1 ~ ~ ~ ~ I 656 Gl/2013 (I) 2 4. THE GAZETTE OF INDIA : EXTRAORDINARY [PART Ill-Sec. 4] (3). "3G<!'fclcti' q;r 3ITTim 6 f.WRuT ;;fl" fln" <FITi,qi" 1ffi,1cf q;rn- tr <\'r ,]$" ;;,~ $ JIM{ 'R ""' fmN mclT ~ ;t- ;,rrmrn- fimur, fct@'m ~. 3fR F.!mr ;t- mm ;t- 3m1R ""' rn fr mc!r icIT ~ 3fucr ~ t I (4). "34':!ifdcll "1i<1ifil:fl qi[ 3ITTim 6 fcl;" q(i "1101ifil{l -,IT ;fl,fifi" qm qi/J:1" ~ ~ ,j;r ,)$" 6 ;;fl" t1J,fllc1 ~ ~ .39./.!ifc1c11 <ti! 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I ( ~ I ! t~ I~ ! t 'Ir 1 I ; i.: .e N i t: ; ir E i l f .~ f_ ..._ t- Ii '"' E ! ~ re ii ' I!: * ~ i ii 1i, I 4o t i 1i : ; I ·--- '"' w ~ i Ii i ; , 1i I l!iilj.j I ~ -lflfM:1 1 1.t 111, ,.lf.j - I -~ilil iiEi;l!ll!l' Jt-~il l 1!1 1!]t1 I.' I i;; iu; ,~ I~ I~ I~ I~ iJ I to IUi /t,; /I;' /tc :;; I i,; I :a' ,...; ' ___ _J_____J__~_____l _ ___l.. _____ J.. ___ L-. __ _L __ _1. ___ L_ __ .J... ___ ....l ___ .L __ _,._ __ ~'---·-..L--.L--L..--..L---'-----'----~-~ 12 THE GAZETTE OF INDIA : EXT&,AORDINARY ., lRIT 3fl"lr.tm~, ~~~;\;-~>l" "ft"'1+<\..1e.i iffrd,i;rlllJli!T.s..rr~, ! WT 1;;-tt fm;-<rr~illl"~.~.3im,<rrpcu,r;\;-~lfi~~? --·-----·---········1___ .. 1 lRIT 3fl"lr.t mf.Rl't ~ ~ <rr ~ ,i;r lll1li!T fll;<rr t- ;m fl!; = ~ ;ft "' __I_ WT 1 ;;-tt __ j --------~- -- --·- -·--- •--·--·- ----------- ------ -- -·-----,.......----- - ,r. ~.ii ,,ma .... , ,i;r ~ t--;~-;;lRIT;;;:;;31Jq'~~~~~~,~~.~~~~~.11~~~,i;r;;;:ai~q~,~~ra~f.h,~~a~i~q,¼A~.,m·~,=ij~,~.,;<rr;;;;;;~;\;-~~~~-;;iw~.c-+-WT-/-;;-tt-,-- ~t1 «. lRIT 3fl"lr.t m ~ ~ ~ .,, f.t<11?tri" I ~ ~ ~ ~ !life. ~ ~ oft, ll'tr.r, mmnr, WT/ ;;-tt 3fffllq, ll,.,)fi14., ~. ~ tm, ;;fr1I" lrad', >nmff<IT <IT il'W lfi1' IR!Cr <IT ~...,.,. ~ wr ~ ~ .r1r.rilr3ITI tr I r,1 Qfr(',_qJ{l ~ ~ ~l'fi«t & ~ AA .mnr 3fiz ~ llfc1Ifclc1 c<lf.fu<l1 <li'r 31R * ~ mf<nm;;n.rr~ 3q{)<Fc-1 -r ft<T -w .nn.r, ~ Jfiz~ .tt ~ <t- ~ ~ m * t!tr cT ~ & tr!~ 31"<1' 01.1fil-a<il <tit 31R * ~ <t-~ ~ ~~ I .ift1J-l$lc1i {~~c::cim~~~-,iiai'l>lfl <t-a'P=rr<!'ffITTft<lir 3fft!R~ !&31\t ,n:- ~ <M = ~1•M~i1 ollm ~ <!;I- 3i\<1$f'e•I ~ <);- 3M.r wft I ~ 'I>! '!.lf ~ = ~ <rr t'r ~ mml'r M tr I~ 3TTir ~ {~ ~ tr~~ <"l -r ~ ~l'fita'r ~ ~ ~ <t- ~me, 'RrT a'P=rr ~ <t- ;itnlt,;fQ"\<liia *~*~~qi)$ q~qi1a1 ~ ~ i:mc!T@ ~ " tr I ~ ~ {~ 3fR ~ 'liT ~ ?;<'IT ~ ~ ~ f<IR'Ur * ~ '"lai <Iii fl f/1;.ft' 3fl' sr<fIT*mTJq; 3lf9c11<>1 & ~ f/1;.ft'afl'<'l"J-l<TtRt@B ~In @ ,.;r ~ f<nm tn" m f/1;.ft' 3fl' ~ m cl¾rro1 f.'l<i~<Fc-11 * t@8 ~In @ * ~ ~rrfrft<li' m J-ll•1ffl'I> f<IR'Ur '"1a1<1i1 fl ,n'.fi- ar ~ & ~ ,;rmftt:r <ht ~ & m f/1;.ft' 3fl' oft"r1, <Iii <II <>1 <1 * t@8 ~/:mc!T @ <t- a'P=rr * ~ ~~ -,ila1<li1fl .,mt ar ~ & ~ ~ ~ <li'r JisHl$R.•I c.m ,t- f.19f!lai ,t- ~ * tn' l 'lT'T III-~ 4J 1. ri z. ' 3. ri "if /p:r~<t;l~~ (it-~~*~ -'iiiiiqiifl ;A~q\('t ~ ~ ~aft m4iRT 311. / <11 Fvi<1,114i ~ ~ wr JfreJii"-,;rar,, ~ ar <l'liclT ~ ~ 3r.lllU, ~ q\f JfreJii"-,;rar,, ~<#;I- .1isHi$R.•i .½I\.~ ~ Fviqc,ii ~~ffl<f~fiw~-'iiT<l'lic!T~. (\lfflid¥ -li" iffili1') ~ ~~ llfdlltH / ~~f.mlir, ~ llfdlhi * 3r.T1I" 8'") 3fi!l'T1T - 11' - 3qc_lifddl cliT ~~ ~~i~d) ilWif ffi" ffl" 3nll{lil• ~cl~lil 3it"{ llij~lfila {fflal) ~ "ffllri S-10- 10-15 8'it 15-20- - <Ii". ~ "!!I". 1l1ftl;i; 31N 3ttJit ifil~ ifilel ~ ~ 31 Bl~ iftl lli«t t, <Ii" • 8'itil:l"narr 58'it 10- 15- 20- "!!I". .nfltm 3lTir / cQ- ~cl~lil 3it"{ llij~lfila ('f!Nal) ~ "ffll" 5-10 10-15 15-20- - - 8'it <Ii". 31111" "!!I". 81111" 20-25- 25·30- 25- 30- 20-25- 25-30 - I 14 TIIE GAZETTE OF INDIA : EXTRAORDINARY [PART 111-S,c. 4] ,, ' - - __ ,_. ____ _] i I if;" ;.;fmr ~ {1FJ / qftqif4,U) I r ·-~--·-·-·--· ---•- I .,;,r,ff,rtlfil,r i -- I a: ~...-il'IJIT -·--· ----··-·- ~,rn;;r-;l;-~;ft;rr - -------- 7f. n.r~f.tnr'>lr.li!T ~;m,.tt-,,-fmt ~ ··----· ---------· ------ -·-··--- tr. -«l'mr'>lr.li!T -.~--- ·-· ·-----·-- ·----- ~~rnr-r I . 16 I • ilmf~if;fftliHDI (Ql~Q~i!il~ /~!if /"41~) "'· Collirlfil"i!l1f ~ .. - ' N. ar. lplillil"Jltt (!lllll\ilt) -er. apiar.r~lllfll- ----··- !'. ~nfll" Sf. .m-nfll" --- ... fflln~cm3l'J ;;r_ ill1f / ~ / ft Q "'ll;";i 15 - ! 7 ;;ftaorcft~ ~ Q(itllii ~~c-~ I ~/rt ~ 'ffilrt 5-10 10-15 15-20 20-25- 25-30 - - lffl - - I "'· m.r-r, :inAr, ili'!l, lil'{ 3!NI' w,timtrittqftiq;r ri,3qcilfiln1lltlnft' ~- ftnl'lllf;fri >r. ~ri 'Ef. ~lf;fri s. ~ 311'{ 31N1'1ITTIT- 'Ef. -~fill ◄a,u.iil tt M ~.~ne.r.r 3ITlt (\l+iil4ilt t, (i+dlit() 16 THE GAZETTE OF INDIA : EXTRAORDINARY 11ta@!i"1l@I:; 34{)ifc1 Rl<o1fh1 att <:__qRr ~ ~ -r$ a1;;iq;1fl 'R 3mllfuf t ~ 3"<'C/lc; cf;; ~'l'R'IT3rr * mt ~ <lJ.i$ll<ll JJ<JTt3tR~a:ratF<li"-ttr ~lj;r~ <;~mm<); 3mm" CR~ 3c'Jle; 344<1'<1 tWrT . " ~: ----- 1. {li'fnl44i ~ / ~lfif ~llil') 2. {li'fill44i -', l\'fnlitl{) Jr.l1n1T - tr - Yfdl~d 3c-ql& -> (~Qql~) 1. fflllilft:'1': 1. ;;ftq.r~ "'""/ ~• 31faa1~a / ~lmltcl/ ~ ~irq>h\;lll'I'/ ~~~<l;' lll'I' I 'lftaR- <l;' m "' "a1r.t~ .t 'l:_il' / "•llf.t~ ' 2. ~l/lt~t ;;fta;r /~"il'il'n liltf.mr/ ffl 3. ~l/lt~ -,~,- ----- --·-·-- 4. ~ l/1t ~q;1fhr llmt ,i;q;fi,l;-;in:.-$ wr s. ditJlr.r lilt~$ iflit <l;' fit• Q fi!t•iifl .i- lm'ar 6. ~ mll'~$"""' lilt '.I" ... fa1Rur ;;rt riill;v ~ lilt r.,u-mft' ~ii/I <llttAl41 mrrt, 7. ijlt' ~ iT>ral'f f.l;q- 'ITiiRlt ;\, Q+'dl44i ~filv <ITit3'11j'R!'tl 8. ~3rllil' QfnlRIH * I. ~,l;-31111R~ ' ii. ..i>r <l;' 311111t~ iii. m i11t ftl1111ft,1 $ 31111R~ '11«1 'Pl - : ~ mi_ '1iiii<t$'6i ~ ![ SlijjUjij; ;f /Pi~C\_<ITTTll•-11fiila m ~#fll:;;f /p;Jllzj~fll:;~~ Rl!f\1\hr-.tt~ ?;llRT <Iii"~ 6 ~ \l@lqqi ~fi\w 344<fi'I ~. ~ 3lltlT{~ ~1R'O<l -,llo-l<til:fl ~ ;,Im fll:; fll:; 3IR c;;;T6" ;f / ~ fn-r,,fro - ~ p; moiurr m ~ fll:; ~ ~ <Iii" Qlq,1R,1 <Iii"~ ~ "'w&=ta<ti"'"<til 'l:t'i" ~ t ~ et ~ ~ f.!14,rr3JR~ra'f. ~. 11'1Pl4J.t llR!il&cll.M if faffil...-1 ~r.-<fi, -;,i'r '"1"'I. ~. ~T@n;r ~ ~: ----- if ~ ~,<),h,t«.mr 31\z t,.,,.,;ct\ RIG!,l'hr ~ ~ ~ ;if (. if ~ ___________ 3l'lilt .- t" ~ (rn'F.R/tlfiTif17r .,,T3ritw";mJ ~ ~ f,l;.n- t 17 (\ifdi44i ~ / ~ ~ f.rffl;rJ ;;i-wt noo ~ ;;nmr # 1!""' Vfdldili ~ Jr.fTqJ r.qr ~ irT ;;rwi R1•Jli+'<IIIH lifdid4i/ 'iftffr.r ~ ~· ftjJ.,)4 ll'J1IT # f 1. (\irii16¥ f+dltH / ~~r.mi.., 2. ------- ~ ~•llfdltH/~~f.lfflir,~ lifdl44i~llii1r tl') I / 18 THE GAZETTE OF INDIA : EXTRAORDINARY INSURANCE REGULATORY AND DEVEWPMENT AUTHORI1Y NOTIFICATION Hyderabad, the 16th February, 2013 Insurance Regulatory and:DevelopmentAuthority (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) oflRDAAct, 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 (I). These regulations may be called the !RDA 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, (! J. 'Act' means the Insurance Act , I 938 (4 of I 938) (2). 'Recommendafion' 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 m: such form as may be prescribed by the jAuthority 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, 1999 ( 41 of 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 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 infonnation 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 of the 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, 1939. " ' 1111""9-__.. ['WT III-~ 4] Chapter II: Obligations 5. Applicability and Scope (I). 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 (I). 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: (] ). 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 THE GAZETTE OF INDIA : EXTRAORDINARY [PART Ill -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. IO. 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 Ill: Implementation l 1. 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 If any 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, Chairman [ADVT. lll/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 Sum Assured I I ,,,, "I Affix latest. ---1 passport size ··~::;a•~ ['1T'T III-~ 4] Term of the Product . Premium Paying Term ' I I Premium Payment Mode (One i time/ Annual/Half Yearly /Quarterly etc.] I ' i (Signature of Proposer) (Signature of Agent/Broker /Bancassurance) (Signature of Insurer)* *At the time of acceptance of proposal Instructions for Proposer: Please follow these carefullv 1 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 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 [PART 1H -SEC. 4] SECTION A: DETAILS OF PROPOSER and/or LIFE ASSURED (Mandatory) ------'- !t_--Personal Details - - -- i a. Name ' .. -·----·· --- ···-- I b. Spouse's Name ·--- -- . c. Father's Name d. Mother's Name -----·· 1---- --____ J_ -·-------· ·-· ···-· e. Gender --- - ··-· ·-- --------· -· f. Date of birth .. •---~- g. Age Proof --· --------------~- - ---··· ·····- h. Identification marks i i. Address for Communication i - ' -- ------- ' j. Permanent Address i i k. Address Proof (Electricity Bill/ L Teieehone BiIILRation Car_<ll'_ - ···-------------··----··· I I. 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 Yes/No habits a) If Yes, whether occasionally or freouentlv (ii). Consuming Alcohol Yes/No b) If Yes, whether occasionally or f- 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 • 7 i a. PAN Number b. Aadhaar Number ---·-· c. Ration Card/ Driving Lice,nse/ Passport Number (* Any one to be submitted) '"-!11 I [ '1T'l III-= 4 l = <liT ~ : 31m>ffiUI 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 ofBirth b. Occupation i 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) I e. lflabour - Number of working days I 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 account7 Yes/No b. If yes, Account No 24 THE GAZETTE OF INDIA : EXTRAORDINARY (PART H!--SEC. 4] c. Account type d. Bank Name and Branch , - -··7 8. Details 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 1---.---- or covered person)_ Rupees] ~- a. Life b. Health c. Unit Linked Insurance Policv d. Pension Polley 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: Appoiniee - Name of Member Details of [whether proposer premium being or covered nersonl oaid fin 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. '""11'1 ,I I I llal "I 11 I .. •••••• ■-,,,._,,, ' I I I ' ' i i 25 Date: (Signature of Proposer/Thumb Impression) (Signature of Proposer) 1. a (Signature/Thumb Impression of Life Assured, if different from Proposer) (Signature ofLlfe Assured, If different from Proposer) SECTION 8: 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 ! b. 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? c. Have you ever been treated or hospitalized for cancer, Tumor, Cysts or any other YES/NO growth? d. Have you ever been referred to an Oncologist or cancer hospital for any investigation or YES/NO treatment? e. Did you have any ailment/Injury /accident requiring treatment/medication for more YES/NO than a week? f. Have you ever been absent from work for more than a week in last 2 years due to any YES/NO illness? g. Were you or your spouse ever tested for Hepatitis B or C, HIV/ AIDS or any other YES/NO sexually transmitted disease? -~-- 26 TIIE GAZETTE OF INDIA : EXTRAORDINARY [PART Ill- SEC. 4] r1: -·-··· - Have you ever suffered Chest pain, Palpitation, Rheumatic fever, Heart Murmur, Heart i i attack, shortness ofBreatli or any other Heart related disorder? t~r.-··ttave you ever suffered symptoms/ailment relating. to Kidney, Prostate, Hydrocele~.A~d- I Urinary System? : ---- ·-------·----·--- - •-"-•• j. Have you ever suffered Gastritis, Stomach or Duodenal.Ulcer, Hernia, Jaundice, Fistula Piles or any other disease or disorders of the Gastrointestinal System? -------- -- -- ---· ·- -···-----· ---- . --- ------ I Have you ever suffered Thyroid disorder or any other disease or disorder of the f Endocrine system? Have you undergone/have been recommended to undergo Angioplasty, Bypass Surgery, Brain Surgery, Heart Valve Surgery, Aorta Surgery or Organ Transplant? ----·-·-'"· I m. Have you ever suffered Diabetes/ High Blood Sugar? i-l-:-,-------=----c=-c-c--=--,-------,-,------------ --- 1 n. Have you ever suffered High/Low Blood Pressure? ~7 YES/NO I ! YES/NO -----; i i ___ J YES/NO ' ' I - -·---- -1 YES/NO i YES/NO ! --·-· ···-- 1 YES/NO YES/NO I - ·------+------·--·---....l ! 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? q. Have you ever suffered Symptoms/ailments relating to Brian, Depression? Mental/Psychiatric ailment, Multiple Sclerosis, Nervous System, Stroke, Paralysis, Parkinsonism or Epilepsy? r--· ------... ·----·------~···· : r. Have you ever suffered Asthma, Bronchitis, Blood spitting, Tuberculosis or other I Respiratory disorders? i- ------------ ------------·-··--·-- ---------- i s. Have you ever suffered Anaemia, Blood or Blood related disorders? ' I 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? l u. Have you ever suffered any other illness or impairment not mentioned above? I i 2. Details of Female Proposers /covered person a. Are you currently pregnant? b. If yes, current months of pregnancy ------ c. State age of first pregnancy d. Have you ever had any abortion, miscarriage or ectopic pregnancy? e. Have you undergone any gynecological investigations, internal checkups, breast checks such as mammogram or biopsy? 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 YES/NO YES/NO I YES/NO I YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO [Note: Insurers may ask appropriate questions based on particular product The above questions are illustrative only.) ,<ill I 'I I'"" I II > I ----1 ! I "'"" J ----- -- 'fl«! '"' ~ : 3f\11>m1'l 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 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) 28 THE GAZETTE OF INDIA : EXTRAORDINARY SECTION C: SUITABILITY ANALYSIS (Highly recommended) ! 1. Affordable contribution-Current and projected (in Rupees) I 7 i,..I _v_EA_R _________ -·-...Jl~..:.!:c.::::.,_jf--' _c..:,~..:.:a=e; __ t-+-Y:..:~:.::!:..:~'-+--'-~~=~::.~!'-+~!., .. :::.::~2:..:'~c-+--'-!o..:.e~=zrs.:.s_+--_!:..:!:.::~3:..:'~c.--1 '. a. Yearly , , r--b·-.--M-o-n-,th-,l_y ____ -----!- --t--f----·····t--···---,f-----.... +-----l·· ·--·- ~----------- -J__. __ _j ____ ~---~ ---~---~---~~---- r 2. ------ .. ·----------··-- - ··-··--····- How do you project your work span? I ' a. Number of Years 5 Years 10 Years 15 Years 20 Years 25 Years 30 Years ! ' 1· "" ------ -·---··· - b. Working span I I 13 Income/Expenditure --Current and projected (in Rupees) I YEAR Last Year Current 5-10 10-15 15-20 20-25 25-30 I Year Years Years Years Years Years a. Income ·- b. Expenditure L ____ . _____________ -· ----------- --··- ---· -- --- ---~-- --·------- -------- ·---------·-- - I 4. Financial details 7 a. Value of savings and assets (in Rupees) I r-----:--::--::--::---::-7=-:--------+-------------~ b. Details of liabilities I .,_. ____ --·--·-----·-----1 c. Expected inheritance _ _____ J I 5. Identified insurance needs (in Rupees) ·- a. Life Insurance ( Death/Maturity) r-·-D;sirable Sum Assured . ____ ,. _____ i 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 'lmf q;y lJ'5jtf'll : 3lm'1R"T ' C Insurance Plan Details ( Tradltional/ULIP /Pension/Health) . 6. ,... ' a. Plan Name ' I l----· b. Premium Type ·---- C, Payment Mode -~ -~-d. Payment Method I /- e. Premium Term l I f. Coverage Term f- i g. Sum Assured (in Rupees) f ----·----- h. Benefits/Riders/Fund Allocation L ----- I 1. Identified Life needs Projections per annum (in Rupees) ' i 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 etc ' b. Education expenses i I I c. Health expenses d. Marriage expenses e. Vacations and other travel expenses --f. Other commibnents such as insurance premium, various contributions etc TOTAL L 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 Ufe Assured, if different from Proposer) (Signature of Life Assured, if different from Proposer) 30 THE GAZETTE OF INDIA : EXTRAORDINARY [PART Jll--SH:. 4] 1. Recommendation: SECTION D: PRODUCT PROPOSED (Mandatory) 1. Life stage -·-·-- --- .. ,.,,~ ,.-•-,,-C-h-i-ld_h_o_o_d_/•Y~nmarried/Yo~~;i;;arried}fuu~g·~;;~i;d"'~'\ ! with children/married with older children/post~family or pi-e- ! j retirement/retirement t··-··-··· - -·- . ______ ,,____ .. -· ---·-· ··-····--·-···-·-. i Life & Health/Savings and Investment/Pension ···--···· _-J_·. I Low /Medium/High I ----------·· l---·-----.. --••-.,--------- I 2. Protection needs ' 3. ----- ·- --- . ·- ,.- Appetite for risk ) 4. Policy recommended, including name of 1 insurer J t--- _,_,, __________________ -----· ---~---- -·· ---· ··-·' - ' -t · 5. Details of commitment for the current and , ' ..... future years ·-···--·· ··---- ________ _!__ 6. Whether all risk elements and details of i charges to be incurred and all other obligations have been explained? 7. Why you think this policy is most suited for the proposer? ----1 \ 8. Whether product proposed is i. Based on need ii. Based on demand i iii. Based on Agent recommendation -----····-L __ _ 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) IHIIlij·----- ·-~i {Signature/Thumb Impression of Ufe Assured, If different from Proposer) / 2. Where the proposer does not accept the Recommendation of the ~ ent Bancassurance Broker and Insurer: (Signature of Ufe Assured, If different from Proposer) ! I am not in agreement with the Recommendation of the Agent/Bancassurance/Broker and Insurer. I have opted I 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, II 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 Ufe Assured, if different from Proposer) Printed by the Manager, Government of India Press, Ring Road, Mayapuri, New Delhi-l 10064 and Published by the Controller of Publications, Delhi-110054.