Purpose of Insurance Loan Risk Cover Savings Tax Benefit Retirement. Children s Education/Marriage. Other (specify)

Transcription

1 Purpose of Insurance Loan Risk Cover Savings Tax Benefit Retirement Children s Education/Marriage Other (specify) Telephone/Mobile Number wherever available Pin Code is mandatory Version No. 1.4 (Traditional Proposal Form) Page 1 of 7

2 d) Number of dependents Page 2 of 7 Version No. 1.4 (Traditional Proposal Form)

3 Version No. 1.4 (Traditional Proposal Form) Page 3 of 7

4 Page 4 of 7 Version No. 1.4 (Traditional Proposal Form)

5 Telephone/Mobile Number wherever available, Pin Code is mandatory Version No. 1.4 (Traditional Proposal Form) Page 5 of 7

6 Consent For Age Extra (Applicable only if non standard age proof is submitted) I hereby agree to pay an extra premium of (`) per thousand sum assured for submission of non standard age proof. I/we do hereby declare that the answers and statements made by me/us in this Proposal Form have been made by me/us after understanding the questions and the said answers and statements are true, accurate and complete in every particular and that I/we have not withheld any information. I/we do hereby agree and declare that these statements and the answers and this declaration along with supporting documents, thereto shall be the basis of this Contract of Assurance between the policy holder and the Canara HSBC Oriental Bank of Commerce Life Insurance Company Ltd (hereinafter referred to as "the Company"), and that if any of the statements and answers and declarations made are found to be untrue, the said contract will be absolutely null and void and all monies which have been paid in respect of this proposal or contract will stand forfeited in favour of the Company (subject to Section 45 of the Insurance Act, 1938). The plan details and riders have been explained to me/us and I/we have opted for the same after understanding the same. I have been explained the nature of questions and the importance of disclosing all material information. If any future premiums or other payments due to the Company are made by us/me, either personally/through its Agent, then the Company will not be liable unless the amounts are received and realized by the Company within the time the Company stipulates for receipt of payments. In order to enable the Company to assess the risk under my proposal and any time thereafter, I hereby authorize my past and present employer(s) doctor/hospital/any Life and Non Life Insurance Company/or organization or Life Insurance Association's medical register to release to the Company and the Company to release to any medical source/any life and non life insurance company/or Life Insurance Association's medical register or Government authorities, such details and provide such records of my employment/business or other details as may be required/considered relevant. I/We give my/our consent to the Company or its agents to undertake the medical tests necessary for assessing my application for life assurance. I/We understand this may involve blood tests including HIV antibodies. I declare that in the event of being medically examined by the Company the answers given to the medical examiner authorized by the Company and in the questionnaires provided by the Company will be deemed to be part of the statements and answers given in this Proposal. I/we agree and declare that I/we will notify the Company in writing, any change occurring in the occupation, financial position, general health of the Life to be Assured or in any of the statements made in the proposal form subsequent to submission of this proposal to the Company but before the commencement of risk or issuance of policy whichever is earlier. I/we also declare that I/we will notify the Company in writing, if any other proposal for Life Insurance with any company is submitted or any request for revival has been made, withdrawn, declined or accepted with increased premium or lien or on terms other than proposed subsequent to submission of this proposal to the Company but before the commencement of risk or issuance of policy whichever is earlier. I/we also hereby agree that any failure on my/our part to notify the Company of the above shall render the contract based on this proposal void and all premiums that have been paid in respect to this contract shall stand forfeited in favour of the Company. I agree that the risk under the Policy will not commence till the Company accepts this Proposal, underwrites the risk and communicates to me the acceptance of the risk on this Proposal by issuing a policy. In case this form is completed by a person other than the Proposer/Life Assured, I/we hereby declare that the contents of the form and documents have been fully explained to me/us and I/we have fully understood the significance of the proposed contract. I authorise the Company to send me updates/information regarding my proposal/policy from time to time through phone calls, text messages or s to my contact numbers and id provided by me herein above, or any other number/ id that I may provide to the Company in future. I acknowledge that the Company has collected and will retain with itself personal information relating to me for the purpose of assessing the risk on my life for which such information is absolutely essential. The Company may also share the same with hospitals/diagnostic centres, reinsurers, life insurance council/association, investigation/verification agencies or vendors as it deems necessary for issuing and administering the policy of insurance. In case I have an objection to usage of my personal information for the purposes mentioned above, I shall intimate the Company prior to its acceptance of my proposal and issuance of the policy, in which case the Company shall cancel the proposal, refund the proposal deposit and delete all sensitive personal information relating to me from its records/systems. In case of Thumb Impression, Left Thumb Impression (LTI) for Males, and Right Thumb Impression (RTI) for Females Signature/ Thumb Impression of Life to be Assured (Proposer signature required if Life to be Assured is a minor) Date D D / M M / Y Y Y Y Place Signature/ Thumb Impression of Proposer Date D D / M M / Y Y Y Y Place Page 6 of 7 Version No. 1.4 (Traditional Proposal Form)

7 I Son/Daughter of, adult and residing at do hereby declare on solemn affirmation as under: I have read out and fully explained the contents of the proposal form and all other documents in language incidental to availing the insurance policy from Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited to Mr./ Mrs./ Ms. and he/she has understood the significance of the proposed contract. I have truthfully and correctly recorded the replies given by the Proposer/Life to be Assured and that the Proposer/Life to be Assured has affixed the signature above after fully understanding the contents thereof. Solemnly affirmed at on Signature of Declarant YOUR COMMUNICATION ADDRESS IS VERY IMPORTANT FOR BETTER SERVICE. PLEASE CHECK IT THOROUGHLY BEFORE SIGNING Section 41 of Insurance Act, ) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out 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 rebate of premium within the meaning of the sub-section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bonafide insurance agent employed by the insurer 2) Any person making default in complying with the provisions of this section shall be punishable with a fine which may extend to `500/- Section 45 of Insurance Act, 1938 No policy of life insurance 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 statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts 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 Page 7 of 7 Version No. 1.4 (Traditional Proposal Form)

8 Place Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited Unitech Trade Centre, 2nd Floor, Sushant Lok, Phase-1, Sector-43, Gurgaon , Haryana, India Toll free at / (BSNL/MTNL) SMS at us at customerservice@canarahsbclife.in Visit us at our website