LIFE INSURANCE

Aditya Birla Sun Life Insurance Company Ltd.

COMMON APPLICATION FORM

IN UNIT LINKED POLICIES, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER
CA Ref A:
CA Ref B:

Insurance Advisor No.

For internal use only

Broker/Corp. Agent No. LF7353 USM Code

Please paste recent
Agency Mgr. No. photograph(3cmx3cm) of the
Specified Person - Broker Verifier Code proposer
Officer of CA/Initiator Code CA5798 self-attested
by him/her
CA Branch Code Verifier Code

APPLICATION FOR INSURANCE ON OWN LIFE / ANOTHER LIFE AGE 18 years & ABOVE
FOR/6/18-19/2939 VER20/JUN/2018

(Please complete the form in BLOCK letters & do not leave any questions unanswered. Use black ink ball pen only)
a) This form to be filled in BLOCK LETTERS WITH A BLACK PEN. b) Any cancellation/alteration in this form to be authenticated by the proposer and all documents submitted
with this Proposal Form must be self attested by the Proposer. c) Insurance contract is based upon utmost good faith between Insurer and the Insured which requires the
Proposer and Life to be Insured to disclose all material facts. d) Please attach an extra sheet, where any additional information needs to be given.

1 LIFE to be INSURED (MINOR) 2 PROPOSER

Do you have an existing policy with ABSLI? Yes No Do you have an existing policy with ABSLI? Yes No
have you currently applied for simultaneous policy have you currently applied for simultaneous policy
If yes, please quote If yes, please quote
Policy/Proposal Number/Client ID Policy/Proposal Number/Client ID
Mobile Number 6900054130 Permanent Account Number (PAN) APNPC9053K
Title Master Miss Mobile Number 6900054130
Full Name Paridhi CKYC Number
Title Mr. Mrs. Ms. Dr.
Chetry Prakash
Full Name
Father/Mother's Name PRAKASH CHETRY
Mother's Name SARITA Maiden Name CHETRY Chetry
Date of Birth 05-10-2013 Father/Mother's Name
Gender Male Female Transgender Date of Birth 09-10-1987
Nationality Indian NRI PIO Relationship with Life to be Insured Natural Parents Legal Guardian
FNIO Others Grandparents
Place of Birth City TEZPUR State ASSAM Others
Minor living with Parents Grandparents Other Gender Male Female Transgender
Studying in School College Mother's Name SARITA CHETRY Maiden Name
State the class in which studying NotStudying/PreSchool Nationality Indian NRI PIO
Age proof submitted FNIO Others
Place of Birth City State
Are you holding citizenship of any other country?* Yes No
If yes please provide country name
Are you a tax resident of any other country?* Yes No
If yes please provide unique tax identification number
*If the response to any of the above questions is yes a detailed NRI questionnaire
will have to be provided
Qualification SSC HSC Graduate Postgraduate Professional
Others
Occupation Service Professional Business Army/ Navy / Police
Skilled Worker Retired Housewife
Others For Armed Forces
3 AGE PROOF submitted for the PROPOSER (Please self-attest) Name of Employer/Business
Aadhar Card Passport PAN Card Type of Organization Govt. Public Ltd. Private Ltd.
Driving Licence Municipal Birth School/College Certificate Partnership Proprietorship HUF
Certificate Trust Society NGO
Others Charity
Nature of Business/Duties OFFICIAL DUTY Designation SOLDIER
*Annual Income Rs. 420000
4 PURPOSE of INSURANCE
*Proof is mandatory only where annualized 1 year premium acrossed all policies held by
Risk Savings Childs Education Childs Marriage Single individual is > Rs.1,00,000
Are you registered person under GST Law? Yes No
Retirement Planning Legacy Planning
If yes provide your GST registration number
Others (Please share the copy of GST registration certificate)

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APPLICATION NO: EM00300790 Form ID: 111001

5 MANDATORY DETAILS IN ACCORDANCE WITH ANTI MONEY LAUNDERING GUIDELINES AS PRESCRIBED BY IRDAI

A Identification Proof of the Proposer (any one) Aadhar Card PAN Card Passport Driving License Others
B Address proof of the Proposer (any one) Aadhar Card Voter Card Passport Driving License Others
Address Type Residential/Business Residential Business Registered Office Unspecified
C Income Proof of the Proposer (any one) (mandatory only if total annual policy premiums to ABSLI is Rs. 1 Lac or above) ITR Others
D PEP - State whether the Proposer or the Life to be Insured or Nominee are Politically Exposed Person @ Yes No
~
E PAN Card copy is mandatory along with the application form if the customer pays Rs. 50,000 or more in a financial year
@
PEP: "Individuals who are or have been entrusted with prominent public functions domestically or by a foreign country or by an international organization,
for example Heads of State or government, senior politicians, senior government, judicial or military officials, senior executives of state-owned
corporationsand important political party officials OR Family members /close associates who are related or have business relationships with PEP.".
~
Form 60 is to be filled and signed by the person who is exempted from the requirement of PAN.

6 ELECTRONIC INSURANCE ACCOUNT DETAILS of PROPOSER

e-INSURANCE A/C details (email address is mandatory) PRAKASHCHETRY01@GMAIL.COM

Yes No I would like to receive my insurance policy and all the information related to the proposed insurance policy through insurance repository.

If opted for the above, please submit requisite annexure with the proposer form

If you already have e-insurance A/C number, please provide the same

e-insurance A/C No Repository Name Karvy Insurance Repository Limited

Would you like to apply. If yes, please mention your preferred Insurance Repository (IR) KARVY NSDL CDSL CAMS

7 ADDRESS for COMMUNICATION with PROPOSER* (all fields are mandatory)

Address 1 VILL - MANSIRI
Address 2 POST OFFICE -MANSIRI
Address 3 DEVENDRANAGAR ROAD
Area GOROIMARI
City/Town/Village TEZPUR
State ASSAM Pin 784105
Proof is mandatory only where annualized 1 year premium acrossed all policies held by Single individual is > Rs. 10,000
Tel. No. Res./Office Alternate Mobile 7814830371
E-mail Address PRAKASHCHETRY01@GMAIL.COM
Your preferred language for communication (select only one) English Hindi Marathi Tamil Telegu
Kannada Bengali Gujarati Malayalam Punjabi
Details where we can send you updates regarding your policy, renewal reminders and ongoing services
Pleases tick on the below box if you wish to receive the renewal reminders, policy statements, ongoing services, various notifications etc. in electronic form
I request you to send my policy documents in electronic form at above email id.
(policy documents will be sent in the physical mode automatically as well).
I request you to send information on my policy regarding renewal reminders, policy statements, ongoing services, various notifications etc. in electronic form at above email id.
Do you wish to receive the renewal reminders, policy statements, ongoing services, various notifications etc Yes No
in physical mode ?
# If the address of life insured is different than the proposer, please fill in the details in "Annexure for Life Insured Address" which forms part of proposal.

8 PERMANENT ADDRESS for COMMUNICATION with PROPOSER (If different from communication address)

Address 1

Address 2

Address 3

Area

City/Town/Village

State Pin
Proof is mandatory only where annualized 1 year premium acrossed all policies held by Single individual is > Rs. 10,000
Tel. No. Res./Office Alternate Mobile
E-mail Address
Your preferred language for communication (select only one) English Hindi Marathi Tamil Telegu
Kannada Bengali Gujarati Malayalam Punjabi
Details where we can send you updates regarding your policy, renewal reminders and ongoing services
Pleases tick on the below box if you wish to receive the renewal reminders, policy statements, ongoing services, various notifications etc. in electronic form
I request you to send my policy documents in electronic form at above email id.
(policy documents will be sent in the physical mode automatically as well).
I request you to send information on my policy regarding renewal reminders, policy statements, ongoing services, various notifications etc. in electronic form at above email id.
Do you wish to receive the renewal reminders, policy statements, ongoing services, various notifications Yes No
etc in physical mode ?
# If the address of life insured is different than the proposer, please fill in the details in "Annexure for Life Insured Address" which forms part of proposal.

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APPLICATION NO: EM00300790 Form ID: 111001

9 INSURANCE PLAN DETAILS

Plan Name BSLI Guaranteed Milestone Option Policy Term 16 years or Whole Life

Basic Premium Rs. - Pay Term 8 years or Regular Pay

Basic Sum Assured Rs. 337500 Savings Date (GSD) years

Increasing Sum Assured 5% 10% (for applicable plans only)

150% 200% 250% 300%

Investment Option A LifeCycle Option Smart Option Risk Profile Conservative Moderate Aggressive

B Return Optimser Option Frequency Monthly Weekly Transfer Date 1st 8th 15th 22nd

C Systematic Transfer Option (Applicable only for monthly mode)

Transfer Fund % % % %
(In increments of 5% with minimum of 5% and maximum of 100% in any fund option. Total must be 100%)

D Self-Managed Option(In increments of 5% with minimum of 5% and maximum of 100% in any fund option. Total must be 100%)
Liquid Plus % Income Advantage % Assure %
Protector % Builder % Enhancer %
Creator % Magnifier % Capped Nifty Index %
Asset Allocation % Maximiser % Multiplier %
Super 20 % Pure Equity % Value & Momentum %
MNC %
(Note: For the Segregated Fund Identification Number (SFIN) please refer the product brochure / leaflet or Benefit Illustration. You may also logon to our website
www.adityabirlasunlifeinsurance.com
If the above mentioned values are not legible, missed or mismatch found with application form, then values from Signed Benefit Illustration will be considered)
ABSLI Waiver of Premium (applicable only if Life to be Insured and Proposer are same)
Riders

Name ABSLI ABSLI ABSLI ABSLI

Sum Assured Rs. Rs. Rs. Rs.

Policy Premium Rs. 2037.75 Instalment Premium Rs. 2129.45 Mode# A S Q M

# Payout mode for Annuity Plan

10(a) PREMIUM PAYMENT DETAILS

Payment Method Direct Bill NACH / Direct Debit Credit Card Salary Deduction Single Premium Others
Payment Mode Annually Semi-Annually Quarterly* Monthly* *not eligible for Direct Bill

Initial Premium Rs. 4258.90 In case of NACH / Direct Debit, Preferred Draw Date 1st 8th 15th 22nd
Top-up Premium Rs. 0 (Incase date is not chosen, policy issuance date will be considered as draw date)
Total Amount paid Rs. 4258.90
(Cheque / DD should be drawn on a local branch of a bank made payable to "ADITYA BIRLA SUN LIFE INSURANCE COMPANY LTD APP NO EM00300790")

Cash (up to Rs. 50,000) Cheque / DD No. Issuing Bank

Date Payable at (Branch)
9-digit MICR code No.
You are requested to pay cash premium only at ABSLI branches or at authorised collection points and not to the advisor or employee.
The company will not be responsible for any loss in this regard.
Source of Funds Salary Business Income Others

10(b) POLICY PAYOUT DETAILS

Payout Mode NEFT ABSLI will make payout(s) to the Proposer, in accordance and subject to the terms and conditions of the policy.

Bank Name STATE BANK OF INDIA Bank Address MEHDIPATNAM

Account Holder's Name Prakash chetry

Account Type Savings Current Account No. 20038757526
9 digit MICR code No. IFSC Code SBIN0011744 (Mandatory)

Please provide a cancelled blank cheque leaf. In case the cheque does not bear the pre printed name of the account holder /bank account number,we will need photocopy of the
bank statement showing account holder's name, address and account number. The bank statement has to be self attested by customer & attested by ABSLI authorized personnel. In
case of any changes in the above bank details in future , please fill up the payout option form available separately along with copy of cancelled cheque and submit the same at your
nearest branch

11 PERSONAL DETAILS OF THE LIFE to be INSURED - MINOR

A FAMILY HISTORY
Has any of minor's parents, brothers or sisters been diagnosed with any hereditary or chronic disorder, heart ailment, high blood pressure, cancer, Yes No
diabetes prior to age 60?
If "YES" give details.

B PERSONAL DETAILS
i Height 168 cms Weight 60 kgs ii Weight gained/lost during the past one year kgs.
Reasons
iii If the minor is under 5 years of age then indicate the weight at the time of birth (in kg.)
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APPLICATION NO: EM00300790 Form ID: 111001

iv Family Physician Name

Tel. Res. Office Mobile E-mail

12 INSURABILITY DECLARATION for the LIFE to be INSURED - MINOR

A Other than normal care at birth, has the minor within the last 5 years received any medical attention from the doctor or any medical treatment by diet, Yes No
medicine or by any other means or been a patient in a hospital or availed of any other medical services?

B Has the minor ever been diagnosed with or treated / consulted for heart disorder, rheumatic fever, cancer, tumor, enlarged glands, anemia, bleeding Yes No
or blood disorder, kidney, urinary or bladder disorder / infection, arthritis, deformity, birth defects, HIV / AIDS or AIDS related complex or undergone
a test indicating the presence of HIV (AIDS) virus, any other illness, surgery or injury?

C Has the minor ever been diagnosed or treated for shortness of breath, asthma, diabetes, sugar in urine, colitis, hepatitis or other liver or digestive Yes No
disorder, fainting spells, epilepsy, nervous or mental disorder? If Yes, submit appropriate questionnaire.

D Does the minor have any health symptoms or complaints for which a physician has not been consulted or no treatment has been received? For Yes No
example, persistent fever, unexplained weight loss, loss of appetite, pain, swelling etc.

Provide complete details for all the above questions answered as "Yes"
Question Exact Diagnosis Details of treating Doctor / Surgeon Date of Diagnosis Date of last Consultation
No. and (Name, Qualification, Contact No.) and Details and date of hospitalization and surgery done
details of current symptoms List of medication being consumed currently

13 INSURANCE HISTORY OF THE LIFE to be INSURED - MINOR

A Is there any concurrent application and/or any existing insurance on minor's life or health in effect with ABSLI or any other insurer in India or Yes No
abroad? If "YES", give details.

Name of the Insurer Sum Assured (in Rs.)

B Has any application on minor's life for life or health-related insurance refused, withdrawn, declined, postponed or offered with restricted Yes No
benefits or with an increased premium or made any claim under any such policy of insurance with ABSLI or any other insurer in India or
abroad? If Yes, give details.

Name of the Insurer Sum Assured (in Rs.) Reasons

C State the number of minor's siblings 1 Brothers 0 Sisters Are all the children insured? Yes No
If "No", give details.

D Give details of family's insurance.

Relationship to Life to be insured Name of the Insurer Year of Issue Sum Assured (in Rs.)
Father MAX LIFE INSURANCE 2014 237000
Mother
Brother(s)
Sister(s)

14 PERSONAL, LIFESTYLE AND MEDICAL DETAILS OF THE PROPOSER (to be completed only if WAIVER OF PREMIUM is opted for)
A PERSONAL DETAILS
i (a) Height 168 cms Weight 60 kgs
(b) Is there any weight change during the past one year? If Yes, give details
ii Family Physician Name
Tel. Res. Office Mobile E-mail
B LIFE STYLE INFORMATION
i Do you intend to live or travel outside India for a period of more than 180 days apart from vacation or pleasure? Yes No
If Yes, submit appropriate questionnaire.
ii Are you involved or do you intend to involve in any hazardous occupation or avocation? Yes No
(for e.g. flying other than a fare-paying passenger, diving, mountaineering, working at heights, underground or offshore, using
explosives or any other dangerous activity) If Yes, submit appropriate questionnaire.
iii Do you consume or have you ever consumed any narcotic substance? If Yes, give details. Yes No
iv Do you consume or have you in the past consumed alcohol or tobacco? If Yes, give details. Yes No

Substance Consumed In the form of Quantity per day No. of years Have you ever been advised to stop consumption
of the substance by a Physician? If Yes, specify the reason.

C FAMILY MEDICAL HISTORY

Has any of your parents, brothers or sisters been diagnosed with any hereditary or chronic disorder, heart ailment, high blood pressure,
cancer, diabetes prior to age 60? If Yes, specify details Yes No

Age (if living) State of Health If deceased, age at death Cause of Death
Father 70 Natural Death
Mother 63 Ok/Good
Brother(s)
Sister(s)

15 PERSONAL, LIFESTYLE AND MEDICAL DETAILS OF THE PROPOSER (to be completed only if WAIVER OF PREMIUM is opted for) contd.

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APPLICATION NO: EM00300790 Form ID: 111001

I) Have you remained absent from place of work on grounds of health for a continuous period of more than 10 days for reasons Yes No
other than pregnancy, minor fracture, cold or flu?

II) In the past five years, have you ever undergone any surgical operation at a hospital or clinic or undergone any investigations with Yes No
other than normal or negative results (including X-rays, ECG, blood tests, biopsies etc.)?

III) Have you ever sought advice or suffered from any of the following? (f) Dizziness / fainting spells, epilepsy, paralysis, stroke, Yes No
mental/ psychiatric disorder or any other neurological
(a) Chest pain, low or high blood pressure, high Yes No
disorder?
cholesterol, heart attack, heart murmur or other
heart disorders? (g) Kidney, urinary, bladder, reproductive organ, prostate Yes No
or any genitourinary disorders?
(b) Asthma, chronic cough, pneumonia, shortness of Yes No
breath, tuberculosis (TB) or other respiratory or (h) Arthritis, gout or joint pain, muscle disorder, bone Yes No
lung disorders ? fracture or any other musculoskeletal disorders?

(c) Diabetes / elevated blood sugar or sugar in the Yes No (i) Disorder of eyes (such as cataract, glaucoma Yes No
urine? etc.) or throat or ears?

(d) Ulcer, colitis, chronic diarrhoea, hepatitis or Yes No (j) Any other illness, surgery, ailment or injury which is Yes No
jaundice or other liver or any gastrointestinal specifically not mentioned above?
disorders?

(e) Cancer, tumour, abnormal growth, cyst, enlarged Yes No

glands or enlarged lymph nodes?

If any of question is answered as Yes, please submit the appropriate questionnaire.

IV Do you have any physical defects, impairment, deformities and / or any condition affecting mobility, sight and / or hearing? Yes No

V Do you have any health symptoms or complaints for which a physician has not been consulted or treatment received? Yes No
(persistent fever, unexplained weight loss, loss of appetite, pain, swelling, etc.)

VI Have you or your spouse received any medical advice, testing or treatment for any sexually transmitted disease or HIV Infection? Yes No

VII For female lives only:

(a) Are you pregnant? If Yes, number of weeks Yes No

(b) Have you suffered from or do you have any gynaecological problems or illness related to uterus / ovaries or breasts? Yes No

Provide complete details for all the above questions under Section 14 answered as
Question Exact Diagnosis Details of treating Doctor / Surgeon Date of Diagnosis Date of last Consultation
No. and (Name, Qualification, Contact No.) and Details and date of hospitalization and surgery done
details of current symptoms List of medication being consumed currently

16 DECLARATION BY THE PROPOSER

I authorize any medical practitioner, hospital, employer, institution or any other person, to disclose to Aditya Birla Sun Life Insurance Company Limited
("ABSLI") any information relating to my health or employment now or at any time in the future.
I authorize the use of email as a mode of communication for various notifications from (to) ABSLI as per ABSLI internal procedures.
I understand and agree that no agent or medical examiner has the authority to waive or vary any stipulations or requirements set by ABSLI.
I understand and agree that the statements and answers given by me (us) during the medical examination (if any) to the medical examiner acting on
behalf of ABSLI and any other documents, medical reports and financial reports required in this application, if any, shall be deemed to be incorporated in
this application.
I confirm that the premiums have not been and will not be generated from proceeds of crime related to any of the offences listed in the Prevention of
Money Laundering Act 2002 and any other applicable statutory provisions as may be in force from time to time.
I have not made any statement to the agent, medical examiner or any other person associated with ABSLI, which in any way modifies the statements and
answers in this application, if any.
I (we) understand and agree that in case of any fraud or misrepresentation, the policy shall be treated in accordance with Section 45 of the Insurance Act,
1938 as amended from time to time.
I understand and agree that ABSLI must be notified of any changes in my / our health and circumstances between the date of this application and prior to
the acceptance of the risk.
I understand and agree that completion of this application in no way implies that a policy for insurance on the Life to be Insured will be issued by ABSLI.
I hereby declare that the contents of this application, if any, for insurance have been fully explained to me and I have fully understood the significance of
the proposed
contract of insurance
I hereby declare that the particulars of the bank account details are true and correct.
I (we) understand and agree that this application form containing my personal information will be shared by ABSLI with its service providers for processing
purpose including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory
authority for the resulting policy only.
I hereby understand that the payout ( if any) shall be received via NEFT mode against the details provided from my end in the application form.
Lastly, I understand and agree that all statements and answers made in this application (proposal for insurance) including contact details or provided in
connection with this application, if any, are true and complete to the best of my (our) knowledge and belief.

Date 06-05-2019 Place TEZPUR IA/ Broker/ SP of CA Code LF7353

PETRUS KANDULNA
Signature or Thumb Impression of the PROPOSER Name of IA / Broker / SP of CA Code

Name & Signature of Witness (in case of Thumb Impression) Signature of IA / Broker / SP of CA Code

VERNACULAR DECLARATION

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APPLICATION NO: EM00300790 Form ID: 111001

I, (full name of declarant) hereby declare that I have explained the contents of the proposal form to the Life to
be Insured/Proposer in _______________________ language and that I have read out to the answers to the questions dictated by me to the Life
Insured/Proposer and that the Life to be Insured/Proposer has/have put his/her thumb impresssion after fully understanding the contents thereof.

Name & Signature of Declarant

I, (Proposer) hereby declare that I have understood the terms & condition of the policy as explained by the declarant.

Signature/Thumb Impression of the PROPOSER/LIFE to be INSURED signing in vernacular language

06