MAX LIFE INSURANCE COMPANY LIMITED

Regd. Office : 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur,
District Nawanshahr, Punjab- 144533
Head Office: 11th & 12th Floor, DLF Square, Jacaranda Marg, DLF City
Phase-II, Gurugram Haryana, 122 002.

PROPOSAL NUMBER:
NON LINKED PROPOSAL FORM
336622642
GO/CA/Broker Code: TC002

Purpose of Insurance: FAMILY LIFESTYLE PROTECTION

Objective of Insurance: INDIVIDUAL POLICY
Product Solution: N/A Affinity Customer: N/A Existing Customer: NO
Do you have Max Life Insurance Policy or have you currently applied for simultaneous policies?      If yes give policy/proposal number? NO

A. Personal Details
Proposer Life to be Insured(if other than proposer)
1. Title MR

First HIMANSHU

2. Name Middle

Last BAJORIA

First BASUDEB
3. Father's / Husband's
Name
Last BAJORIA

4. Gender MALE
5. Date of Birth 28-05-1990
6. Nationality INDIAN
7. Marital Status SINGLE
8. Education PROFESSIONAL
9. Relationship with proposer SELF

10. Industry Type OTHERS

11. Organisation Type GOVT

12. Occupation/Job Title SALARIED
13. Name of Entity / Employer WBSETCL
14. Annual Income(Rs.) 1000000

15. Is the Life to be Insured / Proposer / Nominee / Payor a Politically Exposed Person ? : NO

16. Nominee Details     

Title MR

First RAUNAK

Name Middle

Last BAJORIA

Gender MALE
Date of Birth 27-04-1987
Percentage 50
Relationship with Proposer BROTHER

Title MR

First HARSH
Name
Middle

Page 1 of 5
 Last BAJORIA

Gender MALE
Date of Birth 28-05-1990
Percentage 50
Relationship with Proposer BROTHER

17. Current Residential Address

House NO/Apt Name/Society: PURTI COLORS, BLOCK BLUE 1B

Road/Area/Sector: 12 RAM ROAD BEHALA, SARSUNA

Village/Town: KOLKATA
Landmark:

City: KOLKATA

Pin Code: 700061 State/UT: WEST BENGAL Country: INDIA

Mobile STD
Mobile No. 1: 9674936886 9903024628 Landline:
No. 2: Code:
Email: himanshubajoria786@gmail.com

18. Permanent Residential Address (Optional)

House NO/Apt Name/Society: PURTI COLORS, BLOCK BLUE 1B

Road/Area/Sector: 12 RAM ROAD BEHALA, SARSUNA
Village/Town:
Landmark:
City: KOLKATA
Pin Code: 700061 State/UT: WEST BENGAL Country: INDIA

19. Preferred Mailing Address. Current Residential

20. Preferred language of communication: HINDI
21. Do you wish to hold for this policy electronically under e -insurance ? NO

B. Coverage Information-Type of Coverage

Premium Back Coverage Premium Sum Modal

Base Plan GST
Option Term Paying Term Assured Premium (Rs.)
MAX LIFE SMART TERM PLAN NO 50 50 8000000 10000 1800

Rider/Option Coverage Term Sum Assured Modal Premium (Rs.) GST

MAX LIFE ACCELERATED CRITICAL ILLNESS RIDER 46 500000 1900 342

Modal Premium without GST* and Cess:

GST* and Applicable Cess: 2142 Total Premium Paid: 14042
11900.0
(*GST shall comprise of CGST, SGST/UTGST or IGST (whichever is applicable) including cesses and levies, if any. All applicable taxes, cesses and levies, as per
prevailing laws, shall be borne by you)
a.    Death Benefit Option: Life Cover b.    Life Stage Benefit: YES
c.     Bonus Option: NA
(Not Applicable for plans that offer reversionary Bonus)

2. NEFT Bank A/C Details of Proposer: All Payouts will be credited to this account through Electronic mode of payment. (This will be applicable at select cities
as per facilities/arrangements of Max Life Insurance).
MICR Code: 999999999 Bank Account Number: 38908439923
IFSC Code: 99999999999 Account Holder's Name: HIMANSHU BAJORIA
Type of Bank Account: SAVINGS ACCOUNT Bank Name & Branch: STATE BANK OF INDIA BIDHANNAGAR
Banking Since: NA

3. Permanent Account Number (PAN): AUPPB2459P

TDS may be applicable, in accordance with Income Tax Act 1961, as amended Form 60 required: NO
from time to time.
4. Proof of Possession of Aadhaar (Not Mandatory) XXXXXXXX2946
5. Mode of Payment: ANNUAL 6. Renewal premium by: ECS 7. Source of Funds SALARY
8. Is payor if different from the proposer ? NO

9. Are you a Max Life Agent or an employee of a Max group company/ Corporate Agents? NO

Page 2 of 5
10. Desired Effective Date of Policy: 13-03-2020 23:13:47

11. Premium Payment Details

Amount in Words: FOURTEEN THOUSAND FORTY TWO
Paid Rs: 14042.0 Payment by ONLINE
Cheque / Draft No. / Instrument no SAXG8619779048 Date: 14-03-2020
Bank Name & Branch: NA

C. Information of Life Insured

1. Do you have any life or Critical Illness insurance policy issued, pending approval from any other insurance companies or has
your application for Life/Health/Critical illness insurance or its reinstatement ever been offered at modified terms,rejected or NO
postponed ?

Life to be
Proposer
Insured

2. In the next 12 months do you intend to travel or reside abroad other than on holiday of less than 4 weeks? NO NA

3. Do you participate or do you intend to participate in any hazardous activities as part of your Occupation/ Sports/ Hobby? NO NA

4. Have you ever been convicted or are you under investigation for any criminal charges ? NO NA

5. For Female Life To Be Insured NO

6. For Minor Life To Be Insured (Age &th; 18 yrs.) NA

D. Medical Information

1. Family Details Proposer Life Insured

Has any two (2) or more of your family members (parents & Siblings) ever been diagnosed with diabetes or
NO NA
hypertension or kidney failure or cancer or heart Attack or any Hereditory Disorder before the age of 60 ?

2.

Proposer Life To Be Insured

Height 180 cm NA
Weight 76 kg NA

Life to be
3. Have you ever been investigated, treated or diagnosed with any of the following conditions. Proposer
Insured

i) Diabetes /High blood sugar levels NO NA

ii) Hypertension/ High Blood Pressure, High Cholesterol or Thyroid disorder NO NA

iii) Heart or vascular disorder including chest pain, stroke, heart attack or Angioplasty, CABG or any other heart surgery. NO NA

iv) Breathing or lung disorders including asthma, emphysema, tuberculosis. NO NA

v) Liver or digestive system related disorder including jaundice ,gall bladder, pancreas or Hepatitis B/C. NO NA

vi) Any abnormal growth like tumour,lump,cancer or blood disorder, including anemia or thalassaemia or Sexually transmitted
NO NA
disease ( STD ) including HIV or AIDS.

vii) Any kind of Kidney or bladder disorder, including kidney failure, renal stone, nephritis or prostrate disorder. NO NA

viii) Any neurological or mental health problem like paralysis, multiple sclerosis, Parkinson's, epilepsy, depression or anxiety. NO NA

ix) Muscular-skeletal or joint disorders, including any kind of arthritis, gout, osteoporosis. NO NA

x) Are you having history of any hospitalization, treatment or investigation? NO NA

xi) Have you advised now or in last 5 yrs tests like X-Ray/CT scan/MRI/ Ultrasonography/ ECG/Blood test or any other investigatory
NO NA
or diagnostic tests, or any type of surgery.

Xii) Have you ever been diagnosed with any form of internal or external congenital anomaly or defect i.e. any condition(s) which is
NO NA
present since birth, and which is abnormal with reference to form, structure or position?

Xiii) Have you had any genetic testing before? NO NA

4.Tobacco/Alcohol/Drugs
Do you consume any of the following ?
Consumption:

  Proposer Life Insured

i) Tobacco ( Smoking /Chewing) currently or even occasionally in last 1 year ? NO NA

ii) Alcohol (ML) - Beer/Wine/Hard Liquor. NO NA

iii) Are you taking drugs like Cannabis/Marijuana,Ecstacy,Heroin,LSD,Amphetamines or any other illegal drugs? NO NA

Page 3 of 5
E. Declaration And Authorisation

1. DECLARATION BY PROPOSER AND LIFE TO BE INSURED

I/We hereby declare that I/We fully understand the meaning and scope of the Proposal form and the questions contained above and I am submitting the
completed proposal form of my/our own volition, and confirm that I/We have not been induced by anyone to make the Proposal. I/We have been explained the
nature of questions and the importance of disclosing all material information.

I/We further declare that all the statements and declarations herein shall be the basis of a contract between me/us and the Company and that I/We have made
complete, true and accurate disclosure of all the facts and circumstances and have not withheld any information that may be relevant to enable the Company to
make an informed decision about the acceptability of the Proposal. I agree that in case of any fraud or misrepresentation, action will be initiated as per Section 45
of Insurance Act, 1938, as amended from time to time. I/We undertake to notify the Company, forthwith in writing, of any change in any of the statements made in
the Proposal subsequent to the signing of this proposal and before acceptance of risk and issuance of the Policy by the Company. The first and subsequent year
premium will paid out of legally acquired source of income. I will provide information as and when required by the Company, acting on its own or under any order
or instruction received from Statutory Authorities, as regards to the sources of funds or utilizations or withdrawals. I agree that the Company may provide any
information related to me as available to the Company at any time, to any Statutory Authority in relation to the any laws including the laws governing prevention of
money laundering, applicable in the country. To enable the Company to assess the risk under my/our proposal or for any other purpose in relation to the policy,
l/we, my/our heirs, administrators or executors or assignees hereby authorize my past or present employer(s)/business association/medical practitioners /other
agencies or governmental and/or any regulatory bodies, insurance repositories, CERSAI/ UIDAI, reinsurers / hospitals or diagnostic centres/ other insurance
companies/ service providers to disclose and make available to the Company such details/records, as may be requested by the Company. I understand that I
have disclosed my personal information with Max life and I hereby provide consent to Max Life to share, store my information with its authorized service providers
for servicing this policy/proposal such as issuance, underwriting renewal and claims process with respect to this policy as per the regulation applicable from time
to time. I/We submit the mandate to credit My / Our account towards all payments against the above policy and agree and understand that payouts would be
processed through electronic mode of payment and will be affected at select cities as per facilities/ arrangements of Max Life Insurance. I/We authorize Max Life
to send all communications by E-mail, SMS or any other communication mode. I/We agree to receive regular reminders, updates / alerts from Max life from time
to time.

OTP Confirmation Date: 14-03-2020 17:33:15 Place: KOLKATA

2. DECLARATION BY PRINCIPAL OFFICER/AGENT ADVISOR/SPECIFIED PERSON

I MR. PRASANT BAJORIA having known the Proposer / Life to be Insured for a period of
27 YEARS do declare that I have explained the nature of the questions contained in this Proposal form to him / her. I have also
explained that the answers to the questions form the basis of the contract of the Insurance between the Company and the Proposer / Life to be Insured and if any
untrue statement is contained therein and / or any information that may be relevant to enable the Company make an informed decision, the Company shall have
the right to vary the benefits which may be payable and / or treat the policy voidable at the option of the company subject to section 45 of the Insurance Act, 1938
as amended from time to time. I confirm that to the best of my knowledge the Life to be Insured does not suffer from any physical or mental abnormality or
handicap or has / had been hospitalised, undergone any surgery or treatment, or he /she is involved in activities including any hazardous avocation or occupation
or any other information material for underwriting this proposal form, unless expressly stated in this Proposal. I also declare and represent to the Company that I
am in full compliance with the regulatory requirements applicable to agent / corporate agent / specified person / broker prescribed by the Insurance Act 1938, as
amended from time to time and any other regulation, circular, instruction issued by IRDAI from time to time. I confirm that I have verified the identity, current /
permanent residential address of the proposer/Insured, the nature of his/her business and his / her financial status basis the AML Max Life moral hazard
checklist.

Is this a Replacement Sale? If yes, I have adequately explained the

NA
consequences of replacement sale to the customer.

Relationship of Principal Officer/Agent Advisor/Specified Person with the

Name of Principal Officer/Agent Advisor/Specified Person
Proposer/Life to be Insured

Customer MR. PRASANT BAJORIA

Signature / OTP Confirmation Date / Thumb Impression / Signature / OTP Confirmation Date / Thumb Impression / Electronic Signature of Sales
Electronic Signature of Proposer:- 14-03-2020 17:33:15 Manager 943566

Phone No. with STD Code:-9903024625

We confirm that we have made joint efforts in soliciting the prospect and will be jointly responsible for performing the service related to the policy. We further
confirm that the objective of sharing the commission is not for qualifying for any contest and/or reward & recognition programs of the company.

(Applicable only if more than one Agent Advisors share the commission)

Name(s) of Principal Officer/AA/Spec Person Principal Officer/AA/Spec Person Code % Share

Mr. Prasant Bajoria 943566 100

Important Notes: (1) Any payment/s including initial payment accompanying this proposal, cash or by bearer instrument must be made at any of the Company's
General Office only. (2) Crossed cheque or bank drafts must be made in favour of MAX LIFE INSURANCE COMPANY LIMITED ACCOUNT (Proposal No. as
above) maybe handed over to the Agent Advisor. (3} Receipt of the Completed Proposal and initial payment does not create any obligations upon the Company
to underwrite the risk. The Company shall not be liable until it has underwritten the risk and issued the Policy. If the Policy is sent by post it shall be deemed to
have been delivered to and received by you in the ordinary course within 3 (three) days of posting. We draw your attention to Section - 39, Section - 45 and
Section - 41 of the Insurance Act 1938 which reads as follows-

Section 39: In case nomination facility is availed, section 39 of the Insurance Act, 1938 as amended from time to time shall apply.

Section 45: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of issuance of policy,
from the date of the Commencement of Risk or Revival of the policy or the date of the rider to the policy, whichever is later. However, Insurer may question the
Policy at any time within three years from the date of issuance of policy, from the date of Commencement of Risk or Revival of the policy or the date of the rider
to the policy, whichever is later, on the ground of fraud, in which case insurer shall inform Proposer/Life to be Insured/legal representatives in writing specifying

Page 4 of 5
the grounds and materials on which such decision is based. For other details please referto Section 45 of the Insurance Act, 1938 as amended from time to time.

Section 41: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on
the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the
published prospectuses or tables of the insurer: Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken
out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if at the time of such
acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer. (2) Any person
making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakhs rupees.

Freelook Clause: We shall inform you by a letter forwarding the policy that you have a period of 15/30 days (if the policy is sourced through distance marketing
modes) from the date of receipt of the policy document, to review the terms and conditions of the policy, where if you disagree to any of those terms and
conditions, you have the option to return the policy stating the reasons for your objection. You shall be entitled to a refund of the premiums paid, subject only to
deduction of a proportionate risk premium for the period of cover charges of stamp duty paid and the expenses incurred on medical examination of the Life to be
Insured, if any.

TRAD/mPro/T/0519Ver1.0

Date: 17th Mar 2020

Time: 05:54 PM

Additional Declaration:

I am submitting my Electronic Application of my own volition and have understood the contents of the Electronic Application, and the relevant sales literature
including product features, benefits, applicable charges and am aware of the investment risk under the Policy.

I / We are aware that suitability information has been collected from me/us and recommendation on purchase of life insurance product has been made only
basis such information and any product selected by me/us that differs from such recommendation is on the basis of my/our personal choice. I / we have seen
and understood the benefit illustration shown to me / us on the screen electronically or provided to me / us in physical form, as the case may be. I / we have
disclosed all material information and not withheld any information that may be relevant to enable Max Life to take an informed decision about the acceptability
of the Electronic Application. I also confirm that the information in the Electronic Application, including the state of health and lifestyle habits of the life to be
insured is true and complete. I / we have submitted the confirmation number sent on my mobile number/ email id as a confirmation of the contents of the
Electronic Application and the benefit illustration and agreement to the terms therein.

I/We understand and agree that by submitting the Electronic Application, I / we will be bound by the statements / disclosures of material facts made therein in
the same manner, as if I / we have signed and submitted a written proposal for insurance to the Company and these shall be the basis of a contract between
me/us and the Company. I / we undertake to notify the Company of any change in statements made in the Electronic Application subsequent to its submission
and before acceptance of risk and issuance of the policy by the Company. I / we understand that in case the Company detects any fraud or mis-statement or
suppression of fact material to my/our life expectancy, the Company reserves the right to take appropriate action in accordance with Section 45 of the
Insurance Act.

I / we hereby declare and confirm that details provided in Form 60 attached to this Electronic Application (wherever applicable) are true and correct to the best
of my knowledge and belief. I declare that I do not have a Permanent Account Number and my/ our estimated total income (including income of spouse, minor
child etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which the
above transaction is held will be less than maximum amount not chargeable to tax.

I / we understand that the Company will not be liable unless the premium is received and realized by it within the time period stipulated for the same subject to
underwriting by it. I / we hereby authorize the Company to conduct screening / confirmation of my / our health status through medical examinations on the
basis of which, the Company may accept, decline or offer alternate terms on my proposal. I/we hereby authorize my past and present employer(s) /
associate(s) / medical practitioner(s) / any insurer or any other organization to disclose and make available to the Company my/our information.

I / We have filled the proposal electronically and have received the benefit illustration and filled up proposal form on email and registered mobile OR reviewed
it on tablet / desktop and after observing the said copy, I /we confirm that all the content / information therein is correct to the best of my / our knowledge.

I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately.

Signature / OTP Confirmation Date / Thumb Impression / Signature / OTP Confirmation Date / Thumb Impression / Electronic Signature of Sales
Electronic Signature of Proposer: 14-03-2020 17:33:15 Manager 943566

Phone No. with STD Code:9903024625

Page 5 of 5
Dear Himanshu Bajoria
Greeting from Max Life Insurance!

We are pleased to acknowledge the receipt of your payment of Rs. 14042.00, towards initial payment for the proposal no. 336622642 for Max Life Smart
Term Plan.

We thanks you for choosing Max Life Insurance as your Life Insurance Partner. We look forward to serving you and provide the best of services.

Yours sincerely,

Max Life Insurance Co. Ltd.

Notes:

• The receipt of the complete proposal form and the initial payment made by you, does not create any obligation on us to underwrite the risk. We will not
be liable till the time we have underwritten the risk and issued the Policy.

• This is only an interim confirmation and not a receipt. The final receipt will be issued by Max Life Insurance Co. Ltd. along with the policy document.

• The benefits if any under the Income Tax Act, 1961 would be applicable only after the Policy is issued. We request you to please consult with your tax
consultant for more information.

Max Life Insurance does not give any discount on premium. Please do not believe any such SMS / calls /emails.

Email Helpline
Website Facebook
www.maxlifeinsurance.com service.helpdesk 18601205577 facebook.com/maxlife
@maxlifeinsurance.com 9 AM - 9 PM | Mon - Sat

Service Tax Reg. No. AACCM3201EST001, F 0124-4159397, CIN: U74899PB2000PLC045626

Registered Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr, Punjab -144 533 IRDAI Registration No. 104
Max Life Insurance Co. Ltd, Plot No. 90-A Udyog Vihar, Sector 18, Gurugram (Haryana) - 122015
 Name of the Prospect/Policyholder: Mr. Himanshu Bajoria Proposal No:

Age & Gender: 29 Years, Male Name of the Product: Max Life Smart Term Plan

Name of the Life Assured: Mr. Himanshu Bajoria Tag Line: A Non-Linked Non Participating Individual Pure Risk Premium Life Insurance Plan

Age & Gender: 29 Years, Male Unique Identification No: 104N113V02

Non-Smoker GST Rate: 18.00%

Risk Class:
Max Life State: Haryana
Policy Term: 50 Years
Premium Payment Term: 50 Years Policyholder Residential State: West Bengal

Amount of Installment Premium: `14,042

Mode of payment of premium: Annual

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option Life Cover Sum Assured (in Rs.) `80,00,000
Premium Back Option No Sum Assured on Death (at inception of the policy) (in Rs.) `80,00,000
First Year Monthly Income, if opted (in Rs.) NA Accelerated Critical Illness Option Level
Income Period, if applicable NA Accelerated Critical Illness Sum Assured, if opted (in Rs.) `5,00,000
Income Sum Assured, if applicable `0 Accidental Cover Sum Assured, if opted (in Rs.) `0

Rider Details
Waiver of Premium (WOP) Plus Rider Term NA

Premium Summary
Base Plan Riders Total Installment Premium
Installment Premium without GST (in Rs.) 11,900 - 11,900
Installment Premium with first year GST (in Rs.) 14,042 - 14,042
Installment Premium with GST 2nd year onwards (in Rs.) 14,042 - 14,042

UIN: 104N113V02 Page 1 of 4

 (Amount in Rupees)

Guaranteed Non Guaranteed

Single/ Annualized
Policy Year
Premium Survival Benefits / Loyalty Min Guaranteed Surrender Value Special Surrender Value
Other Benefits, if any Maturity Benefit Death Benefit
Additions

1 11,900 - - - 80,00,000 - -
2 11,900 - - - 80,00,000 - -
3 11,900 - - - 80,00,000 - -
4 11,900 - - - 80,00,000 - -
5 11,900 - - - 80,00,000 - -
6 11,900 - - - 80,00,000 - -
7 11,900 - - - 80,00,000 - -
8 11,900 - - - 80,00,000 - -
9 11,900 - - - 80,00,000 - -
10 11,900 - - - 80,00,000 - -
11 11,900 - - - 80,00,000 - -
12 11,900 - - - 80,00,000 - -
13 11,900 - - - 80,00,000 - -
14 11,900 - - - 80,00,000 - -
15 11,900 - - - 80,00,000 - -
16 11,900 - - - 80,00,000 - -
17 11,900 - - - 80,00,000 - -
18 11,900 - - - 80,00,000 - -
19 11,900 - - - 80,00,000 - -
20 11,900 - - - 80,00,000 - -
21 11,900 - - - 80,00,000 - -
22 11,900 - - - 80,00,000 - -
23 11,900 - - - 80,00,000 - -
24 11,900 - - - 80,00,000 - -
25 11,900 - - - 80,00,000 - -
26 11,900 - - - 80,00,000 - -
27 11,900 - - - 80,00,000 - -
28 11,900 - - - 80,00,000 - -
29 11,900 - - - 80,00,000 - -
30 11,900 - - - 80,00,000 - -
31 11,900 - - - 80,00,000 - -
32 11,900 - - - 80,00,000 - -

UIN: 104N113V02 Page 2 of 4

 Guaranteed Non Guaranteed
Single/ Annualized
Policy Year
Premium Survival Benefits / Loyalty Min Guaranteed Surrender Value Special Surrender Value
Other Benefits, if any Maturity Benefit Death Benefit
Additions

33 11,900 - - - 80,00,000 - -
34 11,900 - - - 80,00,000 - -
35 11,900 - - - 80,00,000 - -
36 11,900 - - - 80,00,000 - -
37 11,900 - - - 80,00,000 - -
38 11,900 - - - 80,00,000 - -
39 11,900 - - - 80,00,000 - -
40 11,900 - - - 80,00,000 - -
41 11,900 - - - 80,00,000 - -
42 11,900 - - - 80,00,000 - -
43 11,900 - - - 80,00,000 - -
44 11,900 - - - 80,00,000 - -
45 11,900 - - - 80,00,000 - -
46 11,900 - - - 80,00,000 - -
47 10,000 - - - 80,00,000 - -
48 10,000 - - - 80,00,000 - -
49 10,000 - - - 80,00,000 - -
50 10,000 - - - 80,00,000 - -

Notes: Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and Goods and Service Tax. Refer Sales literature for explanation of terms used in
this illustration.

UIN: 104N113V02 Page 3 of 4

 I, Mr. Prasant Bajoria (name),have explained the premiums, and benefits under the product fully I, Himanshu Bajoria (name), having received the information with respect to the above, have
to the prospect / policyholder understood the above statement before entering into the contract.

Place:
Date: 3/14/20 Signature / OTP Confirmation Date / Thumb Impression / Date:3/14/20 Signature / OTP Confirmation Date / Thumb Impression /
Electronic Signature of Agent/ Intermediary / Official Electronic Signature of Prospect/ Policyholder
This system generated benefit illustration shall be treated as signed by me.

Page 4 of 4
UIN: 104N113V02 57,29,50,8000000,0,11900.00,M,N,b57