CUSTOMER DECLARATION DECLARATION FORM & DIRECT DEBIT FORM Online Proposal form ID / Application number _______________________________ TO BE FILLED BY THE CUSTOMER
I/We _______________________________________________request _______________________________________________request you to process the proposal with the above mentioned application number submitted online/digitally on the company’s website www.bharti-axalife.com www.bharti-axalife.com Name of Insurance Plan __________________________________________ _______________________________________________________________________________ _____________________________________ The premium payable is ______________________ on a
M
Q
HY
Y frequency for a premium paying term of ___ years
& Sum Assured is _______________________________ From From Agent Name & Code: Code: _______________________________ Mobile No ______________________________ ______________________________ Email ID ___________________________________________________________ ___________________________________________________________ M - Monthly, Q - Quarterly, HY - Half Yearly, Y - Yearly I/We understand that I/we may receive calls from Bharti AXA Life in relation to my application for insurance or the resulting policies. I/We give my consent to Bharti AXA Life to make such calls even when I am/we are registered under NDNC category
DISCLAIMERS
I/We have received, read and fully understood the relevant documentation/information including the KEY feature document, Proposal Form received from _____________________ ___________________________@bharti-axa
[email protected] life.com and have understood and confirm to the product features and Illustration of benefits and the information captured in the Proposal Form. • I/We agree that the answers to the above questions are true and that this addendum forms a part of the proposal/contract between me/us and Bharti AXA Life. I declare that the content of the form and document has been fully explained to me and I have fully understood the significance of the proposed contract. • I/We have submitted the proposal to buy this product on my/our accord after having read and understood the terms and conditions of the said product on company’s website i.e. www.bharti-axalife.com. www.bharti-axalife.com. • I/We have verified the contents of the proposal form and understand and agree that by submitting this proposal for Insurance through the company’s website, I/We will be bound by such statements/disclosures of material facts in the same manner and to the same extent as if I/We had signed and submitted a written proposal for insurance after having read and understood the illustrations of benefits. • I/We fully understand the nature of the questions including health related questions and the importance of disclosing all material information information to the company while answering such questions in the proposal duly filled in online/digital by me or as per the information provided by me. • I/We declare that answers given by me/us to all questions in the online proposal including the information given to the company as to the state of health & habits of the life/lives to be insured are true and complete in every respect. • I/We undertake to notify the company forthwith, in writing of any changes in my/our health, occupational and financial state between the date of this proposal and the date of the acceptance of the risk by the company. • I/We understand that any misstatement, suppression or non-disclosure of material information by me/us or where the company is not notified of any change as mentioned above, the company shall have the right to cancel the policy or to repudiate the claim or to declare the policy void in accordance with Section 45 of the Insurance Act and amount, if any, shall be refunded to the customer based on the policy terms and condition. I/We understand and confirm that the company shall have the sole and absolute discretion to accept, decline or offer alternate terms on this proposal for life insurance. • I/We hereby declare and confirm that I/we am/are making the premium payment towards this proposal through own bank account/credit card and I/we agree to submit a third party declaration in case the premium payment payment is not made from own account. • In case of premium payment through cash, I understand and confirm that I will personally visit the branch office of the company for depositing the cash along with this Customer Declaration Form. • I/We further state and confirm that whatever is stated, declared, confirmed or agreed above are done/effected on my/our own freewill and volition. • I consent agree and hereby state that I have no objection in authenticating myself with Aadhaar based authentication system and UIDAI sharing of my Aadhaar details including name, father’s name, date of birth, address, mobile number, number, email id, gender and image for Aadhaar based validation/e-KYC through biometric and/or One Time Pin (OTP) authentication for the purpose of availing Life Insurance Policy from Bharti AXA Life Insurance Co. Ltd. and servicing of said policy.
SIGNATURE OF PROPOSED POLICY HOLDER (if different)
Ensure you know your policy details SIGNATURE OF LIFE ASSURED
Name: ________________________________________________
Name: ________________________________________________
Date: ________________ Place: ___________________________
Date: ________________ Place: ___________________________
(This section needs to be filled only if ECS has been opted for)
Debit Mandate Form NACH/ECS/DIREC NACH/ECS/DIRECT T DEBIT UMRN
Date
Sponsor Bank Code
CITI000PIGW
I/We hereby hereby authorize authorize
Utility Utili ty Code
CITI000020 CITI0 0002000000 00000037 037 to debit (tick
BHARTII AXA LIFE BHART LIFE INSURANCE INSURANCE CO. LTD. LTD.
)
SB/CA/CC/SB - NRE/SB - NRO/Other
Bank A/C number Tick ( ) CREATE
with bank
MODIFY
an amount of Rupees
CANCEL
IFSC
Name of customer’s bank
FREQUENCY
Monthly
or MICR `
Amounts in words
Qty
H-Yrly
Yrly
As & when presented
DEBIT TYPE
Policy No
Fixed Amount
Maximum Amount
Phone No
Reference
NOT APPLICABLE
Email ID
I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges of the bank PERIOD From
Signature of Primary Account Holder
To Or
1.
Name as in Bank Record
Signature of of Ac Account Ho Hol de der
2.
Name as in Bank Record
Signature of of Ac Account Ho Hol de der
3.
Name as in Bank Record
Until Cancelled
•This is to confirm that the declaration has been carefully read, understood & made by me/us. I am authorizing the user entity/Corporate to debit my account, based on the instruction as agreed and signed by me. •I have understood that I am authorized to cancel/amend this mandate by appropriately communicating the cancellation/amendment cancellation/amendment request to the user entity/Corporate of the bank where I have authorized the debit.
I wish to pay my premium to Bharti AXA Life Insurance Co. Ltd. through a debit to my account on Debit date can be opted from 1 st to 28th. Please note debit date is not available for 29th, 30th and 31st. Please see overleaf for Terms & Conditions
of the calendar.
Application No ______________________
CONFIDENTIAL REPORT BY THE LICENSED SALES PERSON
1.
How do you know the life to be Insured/Proposer___________________________________________ __
2.
If the life to be Insured/Proposer is immediate family* then please specify the relationship ________________________
3.
If the life to be Insured/Proposer is MOA’s/MOM’s Immediate family, then please specify the relationship with MOA/MOM ______________________________
4.
How long have you known the life to be Insured/Proposer ____ Years ____ Months
5.
Income details of proposer (per annum) Salary ______________ Business ______________ Agriculture _________________ Others ______________ Total __________________
6.
Do you have any information of the life to be assured is having or suffered from any illness or surgery or undergone any operation Or undergone any medical Investigation or is physically handicapped or mentally ill.
Yes
No
If reply to any of above is YES, please provide details ____________________________________________ _______________ 7.
Any other risk associated with occupation, sports, pursuit, financial/social position or personal habits of life to be Insured
that could affect the risk in the insurance proposal, please specify _______________________________________________ *Immediate family is spouse, parents, grandparents, grandchildren, siblings & their spouses.
DECLARATION: I, hereby declare that all information as provided in this proposal in connection with this proposal, pertaining to the medical, personal or financial standing of the proposer and having any material effect on the acceptance of this proposal for insurance is true and complete to the best of my knowledge and belief. Should there be any adverse change in my opinion I shall inform the company of the same. I confirm that I have verified the identity, current and permanent residential address of the proposer, the nature of his/her business and his/her financial status. Have verified the financial capacity of the proposer to determine that the premium involved is within the proposer's financial capacity. I certify that I have explained the product brochure and the benefit illustrations to the Proposer and have made no statements which are inconsistent with the same. I fur ther declare that to the best of my knowledge the premium amounts are not sourced from proceeds of any criminal activities/offence listed in the Prevention of Money Laundering Act 2002. Should there be any adverse change in my opinion of the integrity or reputation of the Proposer, I shall inform the Principal Compliance Officer of the company.
Financial/Advisor/Specified Person of Corporate Agent/Broker/Employee
MOA’s/MOM’s/ Branch Sales Head/Senior Manager or above (Sales)
Code: _______________ Designation: ____________________
Code: _______________ Designation: ____________________
Name: ______________________________________________
Name: ______________________________________________
Signature: ___________________________________________
Signature: ___________________________________________
Date: DD MM YYYY
Date: DD MM YYYY
BSM DECLARATION - NON MANDATORY
I confirm that I have met/spoken to the customer for the Life Insurance Proposal. I confirm that the customer is aware of all product features and that the policy sold is in line with the customer’s requirements. The premium paying capacity of the said customer has been established. I have also explained that there are no other benefits apart from the ones mentioned in policy terms & conditions. I approve that the policy is
Self-Policy and/or that is
Splitting of Policy
BSM Signature
Name ___________________________________________ Employee code _________________________ Branch _____________________
INSTRUCTIONS TO FILL NACH 1) UMRN is auto-generated during mandate creation and is mandatory to be updated during amendment and cancellation of mandate. (Maximum length- 20 alphanumeric characters).
17) Names of customer/s and signatures as well as seal of company (Where required). (Maximum length of name- 40 alphanumeric characters)
2) Date in DD/MM/YYYY format.
19) Permanent ID of customer e.g. PAN/Aadhar No
3) Sponsor Bank IFSC/MICR code left padded with zeros where necessary. (Maximum length- 11 alphanumeric characters).
20) Telephone no with STD code of customer.
4) Utility Code of the Service Provider. (Maximum length- 18 alphanumeric characters) 5) Name of Service Provider. 6) Tick on box to select type of action to be initiated. 7) Tick on box to select type of account to be effected. 8) Customer’s legal account number, left padded with zeros. (Maximum length- 35 alphanumeric characters) 9) Name of bank and branch. 10) IFSC/MICR code of customer bank. (Maximum length- 11 alphanumeric characters) 11) Amount payable for service or maximum amount per transaction that could be processed, in words. 12) Amount in figures, similar to the amount mentioned in words. (Maximum length- 13 digit numeric, in paise) 13) Service Provider generated customer reference number. 14) Service Provider generated Scheme/Plan reference number. 15) Tick on box to select frequency of transaction.
18) Undertaking by customer.
21) 10 digit mobile number of customer. 22) Mail ID of customer. 23) On the Policyholder electing the option/mode to pay the renewal premiums, the same, unless revoked and/or modified by him/her subsequently by a 15 days prior written notice to the company, shall be valid and binding on the Policyholder. 24) The Policyholder expressly understands and agrees that if two (2) successive payments/instructions in case of monthly premium payment mode or any one (1) payment/instruction in case of quarterly/half-yearly/yearly premium payment mode, are not received/honored, the company reserves the right to automatically cancel/withdraw the facility forthwith without notice. 25) In case of ULIP policies, payments made on a non-working day or a holiday, NAV (Net Asset Value) applied would be of the next working day. However if the premium is received in advance, the amount will be adjusted on due date and the NAV would be applicable of due date. 26) I/We hereby authorize Bharti AXA Life Insurance Co. Ltd. to debit the revised premium due, on account of change in service tax, education cess or any other charge levied, or by way of any change exercised as per the policy features.
16) Validity of mandate with date in DD/MM/YYYY format.
Registered office: Unit 601 & 602, 6th Floor, Raheja Titanium, Off Western Express Highway, Goregaon(E), Mumbai 400 063. Email:
[email protected], visit us at: www.bharti-axalife.com IRDAI Regd. No: 130, Comp No: Dec-2017-2998, CIN: U66010MH2005PLC157108
