Copy of the Resolution passed in the meeting of the Board of Directors of Ltd. Held on.
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1 Annexure A Proposal No:- Board Resolution in respect of SBI Life Shield used as a Keyman Insurance Policy Copy of the Resolution passed in the meeting of the Board of Directors of Ltd. Held on. Resolved that the Company do take SBI Life Shield used as a Keyman Insurance Cover in the year in respect of Mr./Ms (Designation) of his Company under Plan, for Rs. with all profits, bonuses (wherever applicable) and other benefits on the said policy to accrue to the Company. This Policy shall be taken from SBI Life Insurance Company Limited for a term of years, the premiums of which will be paid by the Company to safeguard the Company from probable losses in the event of his / her demise. Further resolved that Mr/Mrs (Designation), of the Company be and is authorized to negotiate the terms and conditions with SBI Life Insurance Company Limited on behalf of the Company and sign all the papers and documents, including proposal papers, required by SBI Life Insurance Company Limited on behalf of the Company. Certified True Copy For M/s Ltd., Signature Designation Seal of the Company Date: / / Place:
2 Annexure B Special Questionnaire to be filled by the authorized person in respect of SBI Life Shield used as a Keyman SBI LIFE INSURANCE COMPANY LTD Corporate Office: Turner Morrison Building, G.N.Vaidya Marg, Fort, Mumbai Regn No: 111 QUESTIONNAIRE OF SBI LIFE SHIELD USED AS A KEYMAN Bank / Branch Code Selling Branch / Distributor Code Customer Number Policy Number Certified Insurance Facilitator / IA Code Proposal Form No. : INSTRUCTIONS FOR FILLING THE APPLICATION : 1. This application is to be filled by the proposer in BLOCK LETTERS. 2. Please answer to all questions. If any of the questions are not applicable, please write N.A. 3. The proposer and the life to be insured must authenticate any cancellation or alterations in this application. 4. This application has to be attached along with the SBI Life Shield proposal form dully filled along with the other documents asked for. PROPOSER DETAILS 1. Name of the Company / Partnership Organization 2. Office Address Registered Office Address Mailing Address Tel. (Office): Fax : ID: City Pin : State : Tel. (Office): Fax : ID: City Pin : State : 3. Name of business (Full Details) 4. When was the business established? 5. Number of employees in the above named organization 6. Please give details of the turnover; gross profit and net profit before tax for the last 3 financial years. (Please attach audited profit and loss account and balance sheet for the last 3 years. Year Turnover Gross Profit Net Profit (before Tax)
3 7. Please Mention the details in the table given below : Full Name of the Keyman Designation Date of Birth Age Academic and Professional Qualification 8. What s the basis for arriving at the same Sum Assured? 9. What is the object (purpose) of taking this insurance? 10. Are any concurrent applications under Keyman / individual insurance being made to other Life Insurance Companies? Yes/ No[If Yes, please give details Company Policy Type and Term Sum Assured Reason for Cover 11. Please give details of the existing Keyman Insurance Policies on the Life Assured? Company Policy Type and Term Sum Assured Reason for Cover 12. Is there any service agreement with the key employee? Yes/No (if yes give details of the contract with terms and conditions and expiry date) 13. What is the arrangement made to train other person to replace Keyman in the event of his retirement / death/exit? 14. What is the general Retirement Age of the employees in the above named organization? Years LIFE TO BE INSURED / KEYMAN DETAILS 15. Name of the Keyman/life assured proposed to be covered Full Name Middle Name Surname 16..Whether the Board of Directors has passed a resolution to purchase this Keyman insurance. Please submit a copy of this resolution?
4 17. Please give details of the person to be insured, his personal earnings as expressed for income tax for the last 2 years? Particular Year Year Salary or package Dividends Bonuses / Commissions Share of Profit Others (Please give details) TOTAL 18..Whether the Board of Directors has passed a resolution to purchase this Keyman insurance. Please submit a copy of this resolution? Yes No If Yes, please give details in the table mentioned below? Name Age Relationship %of Shares held 19. What Special Knowledge / Expertise does the life assured possess? 20. How long has the life assured been working with this firm? 21. Nature of Duties & how long the life assured is experienced in this field? DECLARATION We hereby declare that the statements from 1 to 21 made are true and complete to the best of our knowledge & belief & that we have not withheld any material information that may influence the assessment or acceptance of this application. We agree that this questionnaire will form part of our application for life insurance and the failure to disclose any material fact may invalidate the contract. We agree to inform the company in writing of any change in our circumstances between the date of this application and the issue of this policy contract. We understand that insurance cover will not commence until the first premium has been received and the policy or acceptance letter has been issued. Signature of the life to be insured (Keyman) Date / / Signature of the Proposer (authorized signatory of the Company) Name Designation Seal of the Company Signature of the Witness: Name of Address of the witness: Place : Date : D D / M M / Y Y Y Y
5 Annexure C Proposal No:- Special Questionnaire to be furnished by Keyman To, SBI Life Insurance CO. Ltd. Mumbai Date : Sir, Re : Proposal No : on the life of Mr/Ms With reference to the above mentioned proposal submitted by me, I have to inform you as regards the following My P A No : My yearly income from all sources before tax is furnished below:- Salary Dividends Director fees Interest on loans Share on retained profits Net income from property Agriculture Income Any other income (Specify) The total insurance on my life in force is to the extent of Rs.. The total amount of insurance premium on the above insurance is Rs. per annum. I further give below the following details of family insurance : Father Mother Spouse Son/s Daughter/s Yearly Income Total insurance in force Total premium Thanking You, Yours truly, (Keyman s Name and Signature)
6 Annexure D Proposal No:- SBI Life Shield used as a Keyman Company s consent for placing Special Endorsement on the SBI Life Shield used as a Keyman Policy It is hereby agreed and declared that in the event of the employee life assured leaving the employment of the employer, the within mentioned Policy be 1. Either Cancelled, or 2. Assigned absolutely in favour of the employee life assured. It is further agreed and understood that no riders are allowed under this policy. The policy will be subject to tax laws applicable from time to time. Authorised Signatory of the Company Signature of the Keyman (Life-Assured) Seal of the Company Place: Date: / /
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