10 BASIC PLAN DETAILS (Select any one option by ticking the box) 10.1 Annuity Provider (1)- Share out of 100%

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1 SBI Life - Swarna Jeevan (UIN - N09V0) To be filed in by employee/ nominee Details of the member on whose life annuity is to be effected Name of the Employee: First Name Second Name Last Name. Name of the Annuitant: Staff no: Date of Birth (DD-MM-YYYY) : : Line - Line - Line - City- State - PIN CODE - Telephone Number: Mobile No: id: PAN NO. : Gender 0 BASIC PLAN DETAILS (Select any one option by ticking the box) 0. Annuity Provider ()- Share out of 00% Annuity Option Details of Second Annuitant(Spouse) (If Joint Annuity is chosen) Name Relation Age 0.. Nominations(First Level) Name Relation Age 0.. Nominations(Second Name Relation Age Level- only in case Joint Life with ROC Option is chosen ) 0. Annuity Provider ()- 0.. Share out of 00%- 0.. Details of Second Annuitant(Spouse) (If Joint Annuity is chosen) Name Relation Age

2 Annuity Option Nominations(First Name Relation Age Level) 0.. Nominations(Second Level only- in case Joint Name Relation Age Life with ROC Option is chosen ) Note: Option Once Exercised shall be Final and Irrevocable Bank Details in the name of First Annuitant only Bank Name Account No* Branch Bank Code# Branch Code# IFSC Code** Account Type MICR Code** Appointee Details Appointee Name Mr/Ms/Mrs (Applicable in case Nominee is Minor) Date of Birth Relation with Nominee Savings Signature Current Frequency of Annuity Payout (Pls tick the appropriate box) Monthly Yearly Quartely Half Yearly Do you want to transfer the Policy to the nearest Branch/Office. Purchase Price: (Rs)(inclusive of service tax) YES/NO.... Cheques/DD/RTGS Particulars: Date of Deposit: Specify Area:

3 Declaration by the Group Administrator I hereby declare that the foregoing statements and answers have been given by me after fully understanding the questions and the I understand that the contract will be governed by the provisions of the Insurance Act 98, and other prevailing statutes and prevailing Signature ofthe Authorised Signatory of the Trust/Company: Signature/ Thumb impression of the first Annuitant: Seal of the Trust/Company Place: Date: Place: Date: Additional Declaration when the membership form is filled by a person other than the group member/group member signs in a vernacular I hereby declare that I have read out and explained the contents of membership form and all other documents incidental to availing the SBI Life- Swarna Jeevan Policy to the Group Member and that he/she said that he/she had understood the same and that he/she agrees to abide by all the terms and conditions of the same. I hereby declare that I have fully explained to the Group Member that the statements contained in this form shall be the basis for the payment of annuity and that if any untrue statement is contained herein, the Company shall have the right to vary the benefits that may be payable, and further, if there has been non-disclosure of a material fact that the membership may be treated as void and all premiums paid under the SBI Life- Swarna Jeevan Scheme may be forfeited to the Company. I hereby declare that I have explained the contents of this form to the Group member in language, that I have truly and correctly recorded the and statements given by the Group Member and that the Member has affixed his/her signature/thumb impression on the membership form in my presence, after fully understanding the contents thereof. Name: Signature of the person making the declaration Signature /Thumb impression of the Member Name and : Signature/ Thumb impression of Spouse Date: Section of the Insurance Act, 98: () No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continuie 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, except such 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 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.

4 () Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees. Section of the Insurance Act, 98: "No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall, after the expiry of two years from the date on Provided that nothing in this section shall prevent the insurer from calling for proof of age any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal." I have attached the following documents with my application:-. Life Annuity Certificate. NEFT Form LA with ROC. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card) Joint Life with ROC Annuity for Life Joint Annuity for LIfe. Concerned Annuity Form. Concerned Annuity Form. Concerned Annuity Form. Pan Card. If Pan Card of spouse is not available, proof. Pan Card. Pan Card. proof (Driving License/ Passport/ Voters id. / Ration Card/ Adhaar Card/ RECHS Card). proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary)(0 Nos.) 6. Details of Nominee along with photograph (0 Nos.). Cancelled copy of cheque for bank. Cancelled copy of cheque for bank. Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or. Photograph of Annuitant (ex- employee. Photograph of beneficiary), Joint Annuitant (spouse) (0 Nos.each) or beneficiary) (0 Nos.) Annuitant (exemployee or beneficiary) and 6. Details of Nominee along with photograph( 0 Nos.) 6. Application Form Joint Annuitant 6. Application Form 7. Application Form 8. Revenue Stamp of 7. Application Form 8. Revenue Stamp of Rs. /- 7. Revenue Stamp of Rs. /- 7. Revenue Stamp of Rs. /- Rs. /-. Pension Form. Copy of PAN Card. Proofs of Main Annuitant and Nominees 6. Age Proofs of Main Annuitants and Nominees 7. Cancelled Cheque 8. Copy of Self Attested Bank Statement 9. Copy of Bank Passbook bearing IFSC Code

5 Details of the member on whose life annuity is to be effected Bajaj Allianz To be filed in by employee/ nominee Name of the Employee: First Name Second Name Last Name. Name of the Annuitant: Staff no: Date of Birth : (DD-MM-YYYY) : Line - Line - Line - City- State - PIN CODE - Telephone Number: Mobile No: 6 id: 7 PAN NO. : 8 9 Gender Male 0 BASIC PLAN DETAILS (Select any one option by ticking the box) 0. Annuity Provider ()- 0.. Share out of 00%- 0.. Annuity Option 0.. Details of Second Annuitant(Spouse) (If Joint Annuity is 0.. Nominations(First Level) Name Relation Age Name Relation Age 0.. Nominations(Second Level- only in case Joint Life with ROC Option is chosen ) Name Relation Age 0. Annuity Provider ()- 0.. Share out of 00%- 0.. Details of Second Annuitant(Spouse) (If 0.. Joint Annuity is Annuity Option 0.. Nominations(First Level) Name Relation Age Mr/Ms. Name Relation Age 0.. Nominations(Second Level only- in case Joint Life with ROC Option is chosen ) Name Relation Age Note: Option Once Exercised shall be Final and Irrevocable Bank Details in the name of First Annuitant only Bank Name Account No* Bank Code# Branch Branch Code#

6 IFSC Code** Account Type MICR Code** Appointee Details Appointee Name Mr/Ms/Mrs (Applicable in case Nominee is Minor) Date of Birth Relation with Nominee Savings Signature Current.... Frequency of Annuity Payout (Pls tick the appropriate box) Monthly Yearly Quartely Half Yearly Do you want to transfer the Policy to the nearest Branch/Office. Purchase Price: (Rs) (inclusive of service tax) Cheques/DD/RTGS Particulars: Date of Deposit: Specify Area: Member Declaration (Please do not sign on blank proposal form) YES/NO I here by declare that the information provided in the above questionnaire is true to the best of my knowledge. I confirm that the answers I Photo of the Main Member Photo of the Joint Member Signature or Thumb Impression of Main Member Signature or Thumb Impression of Joint Life Member Vernacular Declaration If the signature is in vernacular then the proposed insured/proposer should declare below in his/her own handwriting (in the same Signature or Thumb Impression of Main Member Signature or Thumb Impression of Joint Life Member Date- Date- Signature of the witness Date-

7 I hereby declare that the contents of the Application form including the declaration have been explained to the proposer and replies have been recorded as per the information provided by the Counter Member and all the answers have been read out and fully understood by and confirmed by the Counter Member

8 Signature of person filling up the Application form Master Policy Holder Signature and Seal Date- Date- I have attached the following documents with my application:-. Life Annuity Certificate. NEFT Form LA with ROC. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary)(0 Nos.) 6. Details of Nominee along with photograph (0 Nos.) 7. Application Form Joint Life with ROC Annuity for Life Joint Annuity. Concerned Annuity Form. Concerned Annuity Form for LIfe. Concerned Annuity Form. Pan Card. If Pan Card of spouse is not available,. Pan Card. Pan Card. proof (Driving License/ Passport/ Voters id. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary), Joint Annuitant (spouse) (0 Nos.each). proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary) (0 Nos.). proof (Driving License/ Passport/ Voters i.d. / Ration Card/. Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary) and Joint 6. Details of Nominee along with photograph( 0 Nos.) 6. Application Form 6. Application Form 7. Application Form 7. Revenue Stamp of Rs. /- 7. Revenue Stamp of Rs. /- 8. Revenue Stamp of 8. Revenue Stamp of Rs. /-. Pension Rs. /- Form. Copy of PAN Card. Proofs of Main Annuitant and Nominees 6. Age Proofs of Main Annuitants and Nominees 7. Cancelled Cheque 8. Copy of Self Attested Bank Statement 9. Copy of Bank Passbook bearing IFSC Code

9 LIC To be filed in by employee/ nominee Details of the member on whose life annuity is to be effected Name of the Employee:. Name of the Annuitant: Staff no: First Name Second Name Last Name Date of Birth : : (DD-MM-YYYY) Line - Line - Line - City- State - 6 Telephone Number: Mobile No: id: PIN CODE - 7 PAN NO. : 8 9 Gender 0 BASIC PLAN DETAILS (Select any one option by ticking the box) 0. Annuity Provider ()- 0.. Share out of 00%- Male 0.. Annuity 0.. Option Details of Second Annuitant (Spouse) (If Joint Annuity is chosen) Name Relation Age mandatori ly ) 0.. Nominations (First Level) Name Relation Age mandatori ly )

10 0.. Nominations(S econd Levelonly in case Joint Life with ROC Option is chosen ) Name Relation Age 0. Annuity Provider ()- 0.. Share out of 0.. Details of Second 0.. Annuity Option 0.. Nominations(F irst Level) 0.. Nominations(S econd Level only- in case Joint Life with ROC Option is chosen ) Name Relation Age Mobile Share Gen- Name Relation Age Mobile Share Gen- Name Relation Age Note: Option Once Exercised shall be Final and Irrevocable Bank Details in the name of First Annuitant only Bank Name Account No* Branch IFSC Code** Account Type MICR Code** Appointee Details Mr/Ms/Mrs (Applicable in case Nominee is Minor) Appointee Name Date of Birth Relation with Nominee Bank Code# Branch Code# Savings Signature Current.... Frequency of Annuity Payout (Pls tick the appropriate box) Monthly Yearly Quartely Half Yearly Do you want to transfer the Policy to the nearest Branch/Office. Purchase Price: (Rs)(inclusive of service tax) Cheques/DD/RTGS Particulars: Date of Deposit: Specify Area: YES/NO

11 Discharge of Payment/annuity on the Life of Mr./Mrs. On the life of Shri/Ms. (pre populated) I, (pre populated) do hereby acknowledge receipt from the, of the sum of Rs. (Rupees only) in settlement and discharge of all my/our claims and demands in respect of Monthly/Quarterly/Half Yearly/ Yearly instalment(s) of annuity Rs. due from to in respect of the above Assurance. Signature of Shri/Ms. Signature of member/ Beneficiary Dated: Place : Attested by Trustees: Signature of the proposer (Trustees) for self & on behalf of the Co- Trustees of BHEL - Employees' Superannuation Benefit Fund I have attached the following documents with my application:-. Life Annuity Certificate. NEFT Form LA with ROC Joint Life with ROC Annuity for Life Joint Annuity for LIfe. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary)(0 Nos.) 6. Details of Nominee along with photograph (0 Nos.) 7. Application Form. Concerned Annuity Form. Pan Card. If Pan Card of spouse is not available, proof of age is required.. proof (Driving License/ Passport/ Voters id. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary), Joint Annuitant (spouse) (0 Nos.each) 6. Details of Nominee along with photograph( 0 Nos.) 7. Application Form. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary) (0 Nos.) 6. Revenue Stamp of Rs. /-. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary) and Joint Annuitant (spouse) (0 Nos.each) 6. Revenue Stamp of Rs. /- 8. Revenue Stamp of Rs. /- 8. Revenue Stamp of Rs. /-

12 HDFC To be filed in by employee/ nominee Details of the member on whose life annuity is to be effected Name of the Employee: First Name Second Name Last Name. Name of the Annuitant: Staff no: Date of Birth (DD-MM-YYYY) : : Line - Line - Line - City- State - PIN CODE - Telephone Number: Mobile No: id: PAN NO. : Gender 0 BASIC PLAN DETAILS (Select any one option by ticking the box) 0. Annuity Provider ()- Share out of 00% Annuity Option Details of Second Annuitant(Spouse) (If Joint Annuity is chosen) Name Relation Age 0.. Nominations(First Level) Name Relation Age 0.. Nominations(Second Name Relation Age Level- only in case Joint Life with ROC Option is chosen ) 0. Annuity Provider ()- 0.. Share out of 00%- 0.. Details of Second Annuitant(Spouse) (If Joint Annuity is chosen) Name Relation Age

13 Annuity Option Nominations(First Name Relation Age Level) 0.. Nominations(Second Level only- in case Joint Name Relation Age Life with ROC Option is chosen ) Note: Option Once Exercised shall be Final and Irrevocable Bank Details in the name of First Annuitant only Bank Name Account No* Branch Bank Code# Branch Code# IFSC Code** Account Type MICR Code** Appointee Details Appointee Name Mr/Ms/Mrs (Applicable in case Nominee is Minor) Date of Birth Relation with Nominee Savings Signature Current Frequency of Annuity Payout (Pls tick the appropriate box) Monthly Yearly Quartely Half Yearly Do you want to transfer the Policy to the nearest Branch/Office. Purchase Price: (Rs)(inclusive of service tax) YES/NO.... Cheques/DD/RTGS Particulars: Date of Deposit: Specify Area:

14 Declaration by the Group Administrator Ledger & Folio Number Note: The Account Holder / proposer should countersign any cancellation, correction, alteration etc. Attach cancelled cheque bearing the A/c holder s name, IFSC code & bank a/c no.if all three information is not available on the cheque then self attested passbook copy / A/c statement needs to be accompanied along with the cancelled cheque. DECLARATION:.I/We hereby declare that the particulars given above are correct and complete and no blanks have been left. If the transaction is delayed or not effected at all for reason of incomplete or incorrect information, I/We would not hold HDFC Standard Life Insurance Company Limited (HDFC Life) or any of its associates / agents responsible.. I/We undertake to revoke the instruction for NEFT/RTGS/Fund Transfer in the event of the contract being terminated, and further authorize HDFC Life to do so, in my stead, in case the revocation communication is not received within seven days of my knowledge of the aforesaid fact.. I/We further undertake to refund any excess amount whether demanded by HDFC Life or not. This has been credited in excess to my account at any time due to any reason.. I/We agree that the payment will be credited starting from the date that occurs after getting confirmation from bankers of HDFC Life unless the Mandate is revoked and issuance of relevant credit instruction from HDFC Life into the aforesaid account will be a valid discharge to HDFC Life.. I/We further confirm that we understand this mode as a method of payment introduced by Reserve bank of India, which provides us an option to collect our payments, as and when they become due directly through our bank accounts. 6. I/We further confirm that we understand, HDFC Life shall accomplish this by issuing the Payment instruction electronically through its bankers / agent to the Clearing Authority and the Clearing Authority would ensure the credit to our specified bank accounts. 7. I/We further undertake to inform HDFC Life with an advance notice of 6 weeks, in case, I/We desire to change our bank, due to any reason. However, HDFC Life shall retain the right to accept this or reject the same in the case the revised bank are not enabled under this framework. 8. I/we further undertake to inform HDFC Life will have the right to return to the option of paying by cheque if there are more than consecutive failures in remittances for no fault on the side of HDFC Life. 0. In case of non credit to my bank account with/without assigning any reasons thereof or if the transaction is delayed or not affected at all for reasons of incomplete/incorrect information. I would not hold HDFC Life insurance Co. Ltd. Responsible. Signature of Account Holder(s) Proposer Date Place Declaration of the Proposer and the Annuitant(s) I request that the benefits described in this Form be provided to the Annuitant(s) or Nominee(s) as applicable. I declare that all the information given by me in this application is true and I have not withheld any materials fact, which is within my knowledge. I undertake to keep HDFC Standard Life Insurance Company Limited (the Company) informed of any changes in the same. I agree and confirm that these statements and this declaration are the basis of the contract between the Company and the policyholder. If any untrue statements are contained herein or there has been any nondisclosure of any material fact, the Policy to be issued by the Company may be treated as void subject to the provision of Section of the Insurance Act 98. I confirm that I have read and understood the Sales Literature issued by the Company. I understand that the contract will be governed by the provision of the Insurance Act, 98 as amended from time to time and that the same will not commence until the date mentioned in the policy to be issued by the Company. Place: Date: Place: Date (Signature/Thumb impression of Annuitant(s) (Signature /Thumb impression of proposer if different from the Annuitant) Declaration to be made by a third person where: The Annuitant /Proposer have affixed his/her thumb impression; OR the Annuitants/Proposer has signed in vernacular; OR the Annuitants/Proposer has not filled the application. I here by declared that I have explained the contents of this application form to the Annuitants/Proposer in language and have truthfully recorded the answers provided to me. I further declare that the Annuitant /Proposer have signed/affixed his/her thumb impression in my presence. Declarant Name: Signature: Date: : Important Insurance is the subject matter of solicitation. The products mentioned in this proposal from have been approved by IRDA (Insurance Regulatory and Development Authority) and have been allotted an Unique identification Number (UIN). This number is available in our sales literature and also on IRDA s website for verification. Important sections to note under Insurance Act, 98 are provided below: Section of the Insurance Act, 98: () No person shall 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 if the commission payable or any rebate of the premium show of the policy, nor shall any person taking out of 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. Section of the Insurance Act, 98: No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of Life insurance affected after the coming into force of this Act shall, after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee or friend of the insured, or any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statements was on a material matter or suppressed fact which it was material to disclose and it was fraudulently made by the policy holder and that the policyholder knew at the time of making it that the statement was false or that it suppressed fact which it was material to disclose; Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.

15 I have attached the following documents with my application:-. Life Annuity Certificate. NEFT Form LA with ROC. Concerned Annuity Form. Pan Card. proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card) Joint Life with ROC Annuity for Life Joint Annuity for. Concerned Annuity Form. Concerned Annuity Form LIfe. Concerned Annuity Form. Pan Card. If Pan Card of spouse is not available, proof. Pan Card. Pan Card. proof (Driving License/ Passport/ Voters id. / Ration Card/ Adhaar Card/ RECHS Card). proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). proof (Driving License/ Passport/ Voters i.d. / Ration Card/ Adhaar Card/ RECHS Card). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary)(0 Nos.) 6. Details of Nominee along with photograph (0 Nos.). Cancelled copy of cheque for bank. Cancelled copy of cheque for bank. Photograph of Annuitant (ex- employee or beneficiary), Joint Annuitant (spouse) (0 Nos.each). Photograph of Annuitant (ex- employee or beneficiary) (0 Nos.). Cancelled copy of cheque for bank. Photograph of Annuitant (exemployee or beneficiary) and Joint Annuitant 6. Details of Nominee along with photograph( 0 Nos.) 6. Application Form 6. Application Form 7. Application Form 8. Revenue Stamp of Rs. /- 7. Application Form 7. Revenue Stamp of Rs. /- 7. Revenue Stamp 8. Revenue Stamp of Rs. /- of Rs. /-. Pension Form. Copy of PAN Card. Proofs of Main Annuitant and Nominees 6. Age Proofs of Main Annuitants and Nominees 7. Cancelled Cheque 8. Copy of Self Attested Bank Statement 9. Copy of Bank Passbook bearing IFSC Code