REQUEST FOR MAJOR REVIVAL OF POLICY

Transcription

1 Post review of the Mjor revivl form, client my hve to undergo medicl tests/ physicl exmintion (t his/her own cost) In cse of Kotk Hed Strt Joint Life, detils of Secondry Life to e filled in the policy holder's column Policy Numer: Client ID: Emil ID: Proposer: Life Insured (Minor/Mjor): Contct numer Moile numer cdo your it for green world & switch to e-communiction. Kindly mrk if you would like to receive your communiction through electronic mode. If the policy is rejected on the revivl stge Py directly to my nk ccount mentioned here (Plese ttch n originl copy of cncelled cheque with your nme nd nk detils pre-printed on it.) (CTC Complint cheque) Pyment remittnce type Direct credit Nme of the policy holder s per nk ccount Bnk Nme & Address Account Type Svings NRE* Others (if ny) 1) NAME Of: LIFE INSURED POLICY HOLDER (if different from life insured) Ntionlity Mr/Ms/Title Surnme First nme Middle nme cindin cnri/pio cothers Policy Holder: 2) Occuption Detils Life Insured / Proposer (plese tick whichever is pplicle):- ) cprofessionl cself Employed ) Proposer: chousewife cretired cstudent cslried/employed cothers c) If Housewife, plese specify source of income 3) Eduction Detils Life Insured / Proposer (plese tick whichever is pplicle):- ) chsc cnon-mtric cprofessionl cdiplom cilliterte 4) Nme & Address of the Present Employer/Business: cssc cgrdute cpost-grdute cothers ) Proposer: chsc Account No IFSC Code MICR Code *Credit to NRE ccount cn e mde only if premiums were received from NRE ccount cothers cnon-mtric cindin cnri/pio cothers cslried /employed cprofessionl cdiplom cilliterte cssc cself-employed cprofessionl cretired cstudent chousewife cgrdute cpost-grdute cothers Policy holder (if diff. from Life insured) ) Designtion: ) Nture of work: c) Annul Income:

2 5) To e nswered compulsorily Life insured Policy Holder (if different from Life insured) ) Is the occuption of the life insured/proposer ssocited with ny specific hzrds (which would render him/her susceptile to ny injury or illness)? ) Hs there een ny chnge in your occuption, Nture of jo, voction or plce of residence since the dte of signing the originl ppliction? c) Is the life insured/proposer engged in or intends to tke prt in ny hzrdous hoies/ctivities (which would increse the risk of ny injury or illness) d) Do you hve ny history of conviction under ny criminl proceedings in Indi or rod? e) Are you Politiclly Exposed Person (these re the people who hold prominent pulic function viz. Heds/Ministers of Centrl or Stte Govt., Senior Politicins, Senior Govt. Judicil or Militry Officils, Senior Executives of Govt. compnies, Importnt Politicl Prty Officils nd immedite fmily memers of ove persons)? If the nswer to ny of the ove questions is YES, kindly give detils elow: 6) PERSONAL STATEMENT REGARDING HEALTH OF LIFE INSURED / POLICY HOLDER c Height (cms) Weight (kgs) Any history of weight loss or weight gin in lst 1 yer? If yes give detils: 7) Since the Dte of signing the originl ppliction, hve you: Consulted Medicl Prctitioner for ny ilment /injury requiring tretment for more thn 7 dys or remined sent from your plce of work for more thn 7 dys, on helth grounds or climed ginst your helth insurnce policies? Undergone ny crdiologicl / pthologicl or rdiologicl tests? Life insured Policy Holder Life insured Policy Holder 8) Since the Dte of signing the originl ppliction, hve you suffered from / re suffering from: c d e f g h i j k High or low lood pressure, rheumtic fever, chest pin, myocrdil infrction or ny other disese or disorder of the hert or rteries? Jundice, nemi, piles, ulcers, herni, hydrocele, goiter, dietes mellitus or ny other disese of the stomch, liver, spleen, gll ldder or pncres? Asthm, ronchitis, pleurisy, tuerculosis or ny other disese or disorder of lungs? Prlysis, epilepsy, fits or ny kind of nervous rekdown or ny other disese relted to the rin or the nervous system or rthritic, skeletl or joint disorders? Any disese or disorder of er, nose, eyes or throt, including defective sight or hering or dischrge from ers? Cncer, leprosy, rheumtism, gout, enlrged glnds or tumors? Any disese or disorder of kidney, prostte, urinry system or reproductive system Does the life insured hve ny physicl defect / deformity illness / impirment / disility not mentioned ove? Is the life insured or prtner HIV positive or suffering from AIDS, heptitis, gonorrhe, syphilis or ny other venerel disese? Hs the life insured or prtner ever een tested for HIV/heptitis? Hs the life insured ever hd ny ccident requiring hospitliztion or undergone ny tretment or opertion for ny ilment not mentioned ove? Is the life insured pregnnt now or hs the life insured hd ny ortion or miscrrige or cesren section fter the dte of the proposl? (For femle lives only)

3 If the nswer to ny of the ove questions contined in 6 nd 7 ove is YES, kindly give detils elow: Sr. No. Nture of ilment /disese /condition etc Dte of Dignosis Fully recovered / still under tretment Nme, Address nd Telephone Numer of the treting doctor 9) Response compulsory Life insured Policy Holder Hs ny proposl on your life/ ppliction for reinsttement een postponed, declined or ccepted with extr premium or t modified terms y this compny or ny other insurnce compny? Are there ny existing policies, ppliction for revivl of lpsed Policy or fresh proposls on your life, under considertion of this Compny or ny other Insurer? (If yes, plese give detils elow) Policy/Proposl no. Sum Assured On Deth ADB PDB CIB Acceptnce Terms (Stndrd/Rted up/ Deferred/declined/ not completed) Sttus: In Force/ Lpsed (Mention yer of lpse/ Revivl pplied for) 10) Additionl detils Usge of the following Alcohol Tocco Any Nrcotics Life Insured (Answer s 'Yes'/ 'No') Proposer (Answer s 'Yes'/ 'No') Averge usge per dy (pst/ present) Resons for giving up (if pplicle) Current Pst Current Pst LI PR LI PR SECTION 41 OF THE INSURANCE ACT, 1938 (4 OF 1938): 1) No person shll llow or offer to llow, either directly or indirectly, s n inducement to ny person to tke or renew or continue n insurnce in respect of ny kind of risk relting to lives or property in Indi, ny rete of the whole or prt of the commission pyle or ny rete of the premium shown on the policy, nor shll ny person tking out or renewing or continuing policy ccept ny rete, except such rete s my e llowed in ccordnce with the pulished prospectuses or tles of the insurer: Provided tht cceptnce y n insurnce gent of commission in connection with policy of life insurnce tken out y himself on his own life shll not e deemed to e cceptnce of rete of premium within the mening of this su section if t the time of such cceptnce the insurnce gent stisfies the prescried conditions estlishing tht he is on fide insurnce gent employed y the insurer. (2) Any person mking defult in complying with the provisions of this section shll e punishle with fine which my extend to five hundred rupees. DECLARATION BY THE LIFE INSURED AND POLICYHOLDER (if different from the Life insured) I/We declre tht I/We hve nswered the questions in this Policy Revivl Form fter fully understnding the nture of the questions nd the importnce of disclosing ll informtion while nswering such questions. I/We further declre tht the nswers given y me / us to ll the questions in this form re true nd complete in every respect nd tht I/We hve not withheld ny mteril informtion or suppressed ny fct. I/We undertke to notify Kotk Life Insurnce of ny chnge in the stte of helth of the life insured or s to his/her occuption or ny decisions out his/her existing policies or proposls susequent to the signing of this form nd efore the cceptnce of the risk y Kotk Life Insurnce. I/We further declre tht this Policy Revivl Form will lso e the sis of the contrct of insurnce nd if ny untrue sttement is contined in this form, the Compny shll hve the right to vry the enefits which my e pyle nd further if there hs een nondisclosure of mteril fct the policy my e treted s void nd ll premiums pid under the policy my e forfeited to the Compny. I/We herey uthorise the employer, doctor or hospitl of the life insured to divulge to the Compny ny informtion required y them in connection with the policy contrct. I/We understnd tht the contrct will e governed y the provisions of the Insurnce Act, 1938 nd tht the contrct will not commence until the Compny's written cceptnce of this ppliction is received.

4 Dte : Plce : Signture / thum impression * of the Life insured Signture / thum impression* of the Policy Holder (if different from the life insured) * If person other thn the Policy Holder fills the form, then the person filling this policy revivl form on his / her ehlf must sign the following declrtion: DECLARATION BY THE PERSON FILLING IN THE FORM (For forms filled in y scrie or for forms signed in vernculr lnguges) I, hving known the Policy Holder for period of declre tht I hve explined the nture of the questions contined on this ppliction to the Policy Holder. I hve lso explined tht the nswers to the questions form the sis of the contrct of insurnce etween the Compny nd the Policy Holder nd tht if ny untrue sttement is contined therein the Compny shll hve the right to vry the enefits which my e pyle nd further if there hs een nondisclosure of mteril fct the policy my e treted s void nd ll premiums pid under the policy my e forfeited to the Compny. Dte: Plce: Address of scrie: Signture of scrie Signture/Right thum Impression of the Proposer Signture of Advisor/Broker s witness Note: 1. Policy cn e revived post it s discontinunce. The revivl period would end fter 2 yers from the dte of discontinunce or end of lock in period which ever is erlier. 2. Where the policy is ccepted for revivl the discontinunce chrges deducted from the fund will e dded ck to the fund vlue nd units of the segregted fund chosen y the policyholder will e llotted t the NAV s on the dte of revivl 3. Post discontinunce if you wnt to revive the policy nd sme is in mjor revivl then you will hve to complete the mjor revivl formlities. 4. This policy shll e revived only post fresh underwriting of the cse nd fulfillment of ll requirements s my e clled for y the Compny. The policy shll e revived only fter cceptnce of the risk y Underwriters of the Compny nd due communiction of the sme to the policy holder fter clernce of the cheque. Till then the policy shll not e re-instted. 5 Kindly note tht the mount pid y you towrds revivl of your policy re lying undjusted in your policy suspense ccount nd your insurnce cover will not e reinstted unless the requirements re fulfilled. Further, if the required documents re not received within 45 dys from the receipt of the Mjor Revivl Form the mount lying in your policy suspense ccount, will e refunded ck to you without reinstting your policy, fter verifying the credentils of the cse. Plese note this money will not crry ny interest. 6. In order to ide y the Foreign Account Tx Complince Act (FATCA), kindly sumit Insurnce FATCA Declrtion, seprtely, if the nswer to ny of these questions is yes : (i) Are you citizen of ny other country prt from Indi (dul or multiple citizenship); (ii) Are you resident (for tx purposes) of ny other country other thn Indi; (iii) Do you hold green crd of USA or ny similr crd for ny other country? I/We confirm tht I/we shll report ny future chnges in my/our tx sttus to Kotk Life Insurnce within 30 dys of such chnge. I/We lso confirm tht until I/we provide written intimtion out ny such chnges, Kotk Life Insurnce my presume tht there is no chnge in my/our tx residency sttus nd consider my/our erlier sumitted declrtions, if ny, s vlid. I understnd tht for ny queries out my/our tx residency, I/we hve to consult my/our own tx consultnt.

5 A] Mndtory Fields: 1] Contct numer: Moile / residence 2] Occuption, Avoction & Residence Designtion Annexure Guidelines to fill the Mjor Revivl Form Nture of work Annul income If ssocited with occuptionl hzrds relevnt Kotk Life Insurnce Occuption Questionnire to e provided if engged in or intending to tke prt in hzrdous hoies/ctivities Plese specify 3] Eduction: Provision of Income Tx Return 2 lcs or professionl qulifiction certificte my help in the grnting of higher non medicl limits 4] Personl Detils If the life insured is minor - Height/weight to e correctly filled Proposers height/weight if WOP Rider pplied for or if the pln is Long Life Secure Plus or Hedstrt Future Protect Joint Life or Welth Insurnce Plus 5] Medicl questions To e nswered in Yes or No Formt nd wherever Yes relevnt detils to e provided Proposer column to e filled If WOP Rider pplied for or if the pln Long Life Secure Plus or Hedstrt Future Protect Joint Life or Welth Insurnce Pln 6] Existing/Applied policies with Kotk Life Insurnce or other Insurers: Give detils s follows Policy no Pln detils Sum Assured of se pln nd rider if ny Acceptnce Terms [stndrd or rted up or declined or deferred or not completed] Sttus [In force / Lpsed/pplied for revivl etc.] 7] Hits: (Tocco/ Alcohol/ Nrcotics): If usge of ny of the sme is Yes then plese specify: Form of consumption [cigrettes, eedi, pn, Guthk, Beer, Hrd liquor] Usge per dy [sticks,grms,pckets,ml,units,pints] Durtion 8] If policy holder hs signed in vernculr/thum impression then provide SCRIBE DETAILS Nme of scrie Complete Address Sign Dte nd plce of signing B] Additionl Informtion 1] Altertions: Altertion in ny of the following would require sumission of documentry proof long with request for chnge Nme Dte of irth Residentil Address Signture [dul sign formt with previous nd current signtures] Eduction Nominee 2] Income Proof Documenttion: ] If the totl cover on the life insured including the existing nd pplied policies with Kotk Life Insurnce is more thn 15 lcs then ltest income proof would e required ] If totl premium pid either s Proposer Life insured Third Prty Premium Pyer for ll proposls/ policies with Kotk Life Insurnce put together is one lkh or more, ltest income proof is required c] If totl premium pid either s Proposer Life insured Third Prty Premium Pyer for ll proposls/policies with Kotk Life Insurnce put together is 50 thousnd or more, copy of pn crd of premium pyer is required 3] NRI Clients : Plese provide: NRI questionnire Copy of ll the printed pges of the pssport if not sumitted erlier Current residentil ddress in Indi 4] Cncelltion/overwriting on the MRF Should e countersigned ner the plce of overwriting The ove nnexure is intended to help in the filling of the Mjor Revivl Form nd to ensure its completeness in ll respects. It does not form prt of the revivl ppliction nd should not e scnned long with the ppliction. Kotk Mhindr Old Mutul Life Insurnce Ltd. IRDA Regn no.107, CIN: U66030MH2000PLC128503, Regd Office: 4th floor, Viny Bhvy Complex, 159-A, C.S.T. Rod, Klin, Sntcruz (E), Mumi For ny correspondence kindly contct us t : Kotk Infiniti, 7th Floor, Building No. 21, Infiniti Prk, Off Western Express High, Goregon Mulund Link Rod, Generl A.K. Vidy Mrg, Mld (E), Mumi (+9122) {D} {F} Toll Free No: Insurnce is the suject mtter of the solicittion CC\PS\MRF\001 ACKNOWLEDGMENT We cknowledge the receipt of request of Revivl of Policy no.:. Brnch Nme Documents received with this request Dte Time Nme of rnch co-ordintor Signture of rnch co-ordintor Kotk Mhindr Old Mutul Life Insurnce Ltd. IRDA Regn no.107, CIN: U66030MH2000PLC128503, Regd Office: 4th floor, Viny Bhvy Complex, 159-A, C.S.T. Rod, Klin, Sntcruz (E), Mumi For ny correspondence kindly contct us t : Kotk Infiniti, 7th Floor, Building No. 21, Infiniti Prk, Off Western Express High, Goregon Mulund Link Rod, Generl A.K. Vidy Mrg, Mld (E), Mumi (+9122) {D} {F} Toll Free No: Insurnce is the suject mtter of the solicittion CC\PS\MRF\001