: 1QPY013244
CIN L99999MH2000PLC129113
IRDAI Regn. No. 111
³IN CASE OF UNIT LINKED INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER´
INSTRUCTIONS:
KINDLY GO THROUGH THE SALES BROCHURE CAREFULLY AND FULLY UNDERSTAND THE PRODUCT FEATURE BEFORE ENTERING THE
DETAILS.
THE APPLICATION FOR POLICY WILL BE PROCESSED ON THE BASIS OF THE INFORMATION ELECTRONICALLY GIVEN BY YOU IN THIS
WEB BASED APPLICATION FORM.
INSURANCE IS A CONTRACT OF UTMOST GOOD FAITH, WHICH REQUIRES INSURER, PROPOSER/LIFE TO BE ASSURED TO DISCLOSE
ALL MATERIAL FACTS. IN CASE OF ANY DOUBT AS TO WHETHER A FACT IS MATERIAL OR NOT, THE FACT SHOULD BE DISCLOSED.
PLEASE ENTER YOUR CRITICAL INFORMATION LIKE DATE OF BIRTH OR MEDICAL DETAILS ETC. CORRECTLY AS IT IMPACTS THE
TERMS OF THE CONTRACT INCLUDING PREMIUM, FUTURE SERVICING OF THE POLICY AND CLAIMS PROCESSING
PROPOSER SHOULD USE ONLY HIS/HER CREDIT/ DEBIT CARD OR INTERNET BANKING ACCOUNT FOR PAYMENT OF FIRST PREMIUM
DEPOSIT. USE OF CREDIT/DEBIT CARD OR INTERNET BANKING ACCOUNT OF ANYONE OTHER THAN THE PROPOSER WILL LEAD TO
REJECTION OF THIS APPLICATION.
THIS PAYMENT WOULD BE ACCEPTED IN INDIAN RUPEES (INR) ONLY.
Calculate Premium
6. Do you consume or in last five years have you ever consumed tobacco in any form No
(cigarettes / beedis / gutka / cigar, et)?
^FOR MONTHLY MODE, 3 MONTHS PREMIUM IS TO BE PAID IN ADVANCE AND RENEWAL PREMIUM PAYMENT IS ALLOWED ONLY
THROUGH ELECTRONIC CLEARING SYSTEM (ECS) or STANDING INSTRUCTIONS (WHERE PAYMENT IS MADE EITHER BY DIRECT DEBIT
OF BANK ACCOUNT OR CREDIT CARD).
Basic Details
Personal Details
E-INSURANCE
e - Insurance Account NA
Number
#ADDITIONAL DETAILS WILL BE REQUIRED
18. Is your permanent address the same as your mailing address? Yes
Nominee Details
NOMINEE 1 DETAILS
1. Full Name Mr. A RAVI
Other Details
1. Occupation Service
Name of employer / workplace State Government Specify the exact designation School Assistant
4. Do you file your Income tax Return (ITR) and have FORM 16 from previous year? Yes
5. Are you exposed to any special hazard associated with your occupation? No
7. Do you have any history of conviction under any criminal proceedings in India or abroad? No
8. Do you have any other individal life insurance policy or haveyou applied for one? (It may include No
policies taken from or proposals applied with SBI LIFE or any other life insurance company)
9. Is any of your proposals rejected, declined, postponed, or accepted with additional premium by any No
insurance company?
Name Policy / Year Product / Under - Yearly Sum Assured (In Premium Paid Policy
of Insurance Proposal of Plan / Rider / gone Premium Rs.) for Self/ Status
Company No. Issue Option Medical (In Rs.) Spouse/
s (Yes/ Parent
No) (Pls. specify)
NA NA NA NA NA NA NA NA NA
H. Please submit any of the below listed documents for Direct Credit of any Refunds / Payout if any, to this account
Cancelled Cheque
I DECLARE THAT THE INFORMATION GIVEN ABOVE IS TRUE AND CORRECT. I SHALL NOT HOLD SBI LIFE RESPONSIBLE FOR NON-
CREDIT/NON-PAYMENT OF PAYOUT OR REFUND IF ANY, DUE TO ANY REASON INCLUDING BUT NOT LIMITED TO
INCORRECT/INCOMPLETE INFORMATION. I HEREBY AUTHORISE SBI LIFE TO DIRECTLY CREDIT PAYOUT/REFUND, IF ANY, TO THE
ABOVE MENTIONED ACCOUNT.
Lifestyle Details
1. Do you consume or in last five years, have you ever consumed tobacco in any form (cigarettes / beedis / gutka / cigar, etc)? No
3. Do you consume or have ever consumed Narcotic substances or addictive drugs in any form? No
4. Do you take part in any adventurous hobbies/activities that could be dangerous in any way, such as aviation (other than fare paying No
passenger), mountaineering,any form of racing, etc?
6.1 Are you presently pregnant or have delivered a child in last three months? No
6.2 Have you ever had any abortion or miscarriage ? (If so, enclose the Gynaecologists report) No
6.3 Have you ever suffered/are you suffering from / undergone any investigation/received any medical advice/consulted a physician for No
any gynecological problem related to uterus, cervix, ovary, breasts,etc or undergone surgical procedure like hysterectomy etc?
6.4 Have you undergone a Family Planning Operation? No
Name Of Insurance Company Policy Number Yearly Premium (In Rs.) Sum Assured (In Rs.)
NA NA NA NA
Family Members Status Present Age / Present Status of If Dead, Cause of Please Specify
Age at Death Health Death
Father Alive 65 Good
Medical History
1. During the last 5 years, whether you were under any medical treatment or regular monitoring or remained absent from your place of work
No
(Professional or Non Professional) on grounds of health, injury, mental condition or sickness for more than 7 consecutive days ?
2. Do you have any physical deformity or congenital/acquired defect or impairment of hearing or vision or irregular gait or involuntary
No
movements of limbs or require assistance in carrying out your routine activities (support of wheel chair etc)?
4. Are you suffering from, or did you suffer or undergone investigation in the past from or have you been advised to undergo investigation or
treatment for any form of heart disease (chest pain, palpitation, rheumatic fever, heart murmur, vascular/ valve disease, angioplasty, No
bypass, heart enlargement, cardiomyopathy, atherosclerosis or any other heart disease)
5. Have you met with any accident or suffered from any physical impairments / head injuries / loss of Consciousness Due to any accident? No
6. Do you have high Blood pressure or have you ever suffered or treated or have you been advised to undergo investigation for High Blood
No
pressure?
7. Do you have diabetes or have you ever suffered or treated or have you been advised to undergo investigation for high blood sugar or
No
diabetes?
8. Are you suffering from, or did you suffer from or undergo investigation, treatment, hospitalisation or surgery in the past or have you been
advised /referred to undergo investigation or treatment or visit a doctor for any of the following conditions- Cancer/ leukemia/ lymphoma/ No
malignancy of any form
9. Kidney disease (stones, blood in urine, acute / chronic disease/ infection, renal failure, replacement, need for dialysis etc) prostate or
No
other urinary system disease or disorder
10. Liver disease (jaundice, hepatitis B, C, fatty liver, cirrhosis, alcohol related disease or disorder etc) No
15. Mental disorders (depression, anxiety or any other psychiatric problem, neurosis, psychosis, panic attack, attempted suicide etc.) No
16. Chronic infections/Circulatory/Blood disorder / Anaemia / Thalassemia major / Bleeding disorders, Rheumatoid arthiritis,Sle or any other
No
auto immune or connective tissue disorders etc
17. Brain / nervous system disease / stroke, blackouts, epilepsy or other neurological (Nerves, e.g. parkinsons disease (shaking / tremor
No
disease), etc
19. Eye disease / Ear disorders or any Skin disorders (psoriasis etc)? No
I hereby declare that the foregoing statements and answers have been given by me after fully understanding the questions and the
same are true, accurate and complete in every manner and that I have not withheld or omitted to give any information. Further, I
have not provided any false information in reply to any question. I understand and agree that the statements in this proposal
constitute warranties. I do hereby agree and declare that these statements and this declaration shall be the basis of the contract of
assurance between me and SBI Life Insurance Co. Ltd. (Company) and that if there is any mis-statement or suppression of material
information or if any untrue statements be contained therein the amount payable shall be in accordance with Section 45 of the
Insurance Act 1938, as amended from time to time.
I also understand and agree that the company shall additionally levy or recover all the applicable taxes like service tax, surcharge,
cess, GST, etc. which are necessitated by various enactments of Central and/or State Legislatures from time to time.
I undertake to undergo all medical tests as may be required by the Company for the grant of insurance.
Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital
and/or employer from divulging any knowledge or information about me concerning my health, employment on the grounds of
secrecy, I, my heirs, executors, administrators and assignees or any other person or persons having interest of any kind
whatsoever in the policy contract issued to me, hereby agree that such authority, having such knowledge or information, shall at
any time be at liberty to divulge any such knowledge or information to the Company.
I further agree that if after the date of submission of this proposal but before the issue of the premium receipt by the Company (i) if
there are any adverse circumstances connected with the general health of myself, or (ii) if a proposal for assurance on my life made
to any other insurance company has been withdrawn or dropped or accepted at an increased premium or on terms other than as
proposed by me, or, (iii) if there is any change in my occupation, I shall forthwith intimate the same to SBI Life Insurance Co. Ltd. in
writing to reconsider the terms of acceptance of this proposal. Any omission on my part to do so shall render the contract of
assurance invalid. In the event that this proposal is not converted in to a policy, I agree that the Company has the right to recover
from me, any medical expenses incurred by the Company. I understand and agree that SBI Life will not be responsible for any
delay in premium payment irrespective of any mode for remittance opted.
I understand the significance of the contract and that the contract will be governed by the provisions of the Insurance Act, 1938, as
amended from time to time, IT Act, 2000 and the Indian Contract Act, 1872, and that the same will not commence until written
communication about acceptance of this proposal by the company is received by me. I also agree that the amount held in
proposal/policy deposit shall not earn any interest.
I further state that I have thoroughly read the product features and have completely understood the terms and conditions of the
policy and agree that by submitting this application through the company's website, I will be bound by such statements/disclosures
of material facts in the same manner and to the same extent, as if I have signed and submitted the written proposal for insurance to
the company.
"I further consent for SBI LIFE sending me any information relating to this proposal / resulting policy and I hereby give my consent
to receive such information through SMS/ Email/ Phone/ Letter, notwithstanding any Regulations/ Statutory provisions to the
contrary. This consent shall hold good even if I register my number with the National Customer Preference Register (NCPR)"
I hereby understand and agree that no physical policy document will be issued to me if I have requested for issuing this insurance
policy in electronic format to my einsurance Account.
³I hereby declare that the deposit for this proposal has been paid from my own source/ income´I further declare that the premium is
paid from my credit / debit card / internet bank account.
1) 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 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.
2) Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten
lakh rupees.
No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the
policy. A policy of life insurance may be called in question at any time within three years from the date of the policy, on the ground
of fraud or on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was
incorrectly made in the proposal or other document on the basis of which the policy was issued or revived or rider issued. The
insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured, the
grounds and materials on which such decision is based.
No insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement or
suppression of a material fact was true to the best of his knowledge and belief or that there was no deliberate intention to suppress
the fact or that such mis-statement or suppression are within the knowledge of the insurer. In case of fraud, the onus of disproving
lies upon the beneficiaries, in case the policyholder is not alive.
In case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on the grounds of
fraud, the premiums collected on the policy till the date of repudiation shall be paid.
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.
For complete details of the section and the definition of µdate of policy¶please refer Section 45 of the Insurance Act, 1938, as
amended from time to time.
I, Mrs. A Vidya understand and agree that by submitting this proposal through the Company's website, I will be bound by such statements / disclosures
of material facts in the same manner and to the same extent, as if I have signed and submitted a written proposal for insurance to the Company.
Place :-HYDERABAD
Date :- 14-Dec-2018
Place HYDERABAD
ȈI am aware that Central Board of Direct Taxes ȋDzCBDTdzȌhas notified Rules 114F to 114H as part of the Income-tax Rules, 1962, (read
alongwith FATCA/CRS instructions given below) which require Indian
financial institutions such as SBI Life to seek additional personal, tax and beneficial owner information and certain certifications and
documentation from all our proposers/ accountholders.
ȈI understand that SBI Life is relying on information provided in this form for the purpose of determining the status of the accountholder
in compliance with FATCA/CRS. SBI Life is not able to offer any tax
advice on FATCA or CRS or its impact on me.
ȈI acknowledge my responsibility to seek advice from professional tax advisor for any tax questions.I agree to submit a new form within
30 days if any information or certification on this form changes or
becomes incorrect.
ȈI agree that as may be required by domestic regulators/tax authorities, SBI Life may be required to report, reportable details to CBDT
or other authorities/agencies or may be required to provide
information to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the policy/(ies) or
any proceeds in relation thereto or even close or suspend my
policy/(ies), as appropriate.
ȈI hereby declare that the details furnished in the proposal no. specified above and in this declaration are true and correct to the best of
my knowledge and belief and I undertake to inform SBI Life of any changes there in,immediately. In case any of information furnished in
the proposal no. specified above and in this declaration is found to be false or untrue or misleading or misrepresenting, I am aware that I
may be liable.
ȈI hereby authorize SBI Life to consider details furnished in the proposal no. specified above and in this declaration for the purpose of
Central KYC Registry and to provide my details to CERSAI in the prescribed format. I further hereby consent to receiving information
from Central KYC Registry through SMS/Email or registered mobile number/email address mentioned in the proposal no. specified
above.
ȈI hereby authorize the company to provide my/ours details to banks,financial institutions and third party service providers that the
company may have tie-ups with, for verification of proposal details and for servicing of policies.
FATCA/CRS Instructions
In case Proposer/Accountholder has the following Indicia pertaining to a foreign country and yet declares self to be non-tax resident in the respective
country, to provide relevant Curing Documents as mentioned below:
FATCA/ CRS Indicia observed (ticked) Documentation required for Cure of FATCA/ CRS indicia
List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body**
2. Valid identification issued by an authorized government body**(e.g.Passport,National Identity card, etc.)
**Government/ agency thereof or a municipality of the country or territory inwhich the Proposer/Accountholder claims to be a resident.
IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER
Insurance Regulatory & Development Authority of India (IRDAI) requires all life insurance companies operating in India to provide official illustrations to their customers. The illustrations
are based on the investment rates of return set by the IRDA (Linked Products) Regulations, 2013 and is not intended to reflect the actual investment returns achieved or which may be
achieved in future by SBI life Insurance Company Limited. The two rates of investment return currently declared by the Regulations are 4% and 8% per annum.
The main objective of the illustration is that the client is able to appreciate the features of the product and the flow of benefits in different circumstances with some level of
quantification. For further information on the product, its benefits and applicable charges please refer to the sales brochure and/or policy document. Further information will also be
available on request.
Some benefits are guaranteed and some benefits are variable with returns based on the future fund performance of SBI Life Insurance Company Limited. If your policy offers guaranteed
returns then the same will be clearly marked as 'guaranteed' in the illustration. If your policy offers variable returns then the illustration will be based on two different rates of assumed
future investment returns. These assumed rates of return are not guaranteed and they are not the upper or lower limits of what you might get back, as the value of your policy is
dependent on a number of factors including future fund investment performance.
1. Kindly note that this is an illustration only and does not in any way create any rights and/or obligations. The actual experience on the contract may be different from what is
illustrated. The non-guaranteed low and high rate mentioned relate to assumed investment returns at different rates and may vary depending upon market conditions. For more details
on risk factors, terms and conditions please read sales brochure carefully before concluding purchase.
2. The unit values may go up as well as down and past performance is no indication of future performance on the part of SBI Life Insurance Co. Ltd. We would request you to appreciate
the associated risk under this plan vis-a-vis the likely future returns before taking your investment decision.
3. Please read this benefit illustration in conjunction with Sales Brochure and the Policy Document to understand all Terms, Conditions & Exclusions carefully.
4. This illustration has been prepared in compliance with the IRDA (Linked Products) Regulations, 2013.
Personal Details
Date 14/12/2018
Fund Details
Insuarnce Plan Unique Policy Premium Sum Annualized Monthly Sum Assured
Identification Term Paying Assured Premium Premium
Number (UIN) (Years) Term Multiple
(Years) Factor
SBI Life - eWealth Insurance 111L100V02 15 15 10.00 Rs. 36,000 Rs. 3,000 Rs. 3,60,000
Agent / CIF / Sales Intermediary Name Direct Channel Agent/ CIF/ Sales Intermediary Code Not Applicable
1 36,000 - 36,000 540 406 946 214 35,588 244 35,343 32,841 3,60,000 405 945 215 36,326 248 36,078 33,530 3,60,000 -
2 36,000 - 36,000 540 381 921 292 72,282 704 71,578 69,879 3,60,000 379 919 296 75,217 726 74,490 72,791 3,60,000 -
3 36,000 - 36,000 540 354 894 369 1,09,907 1,158 1,08,748 1,07,474 3,60,000 348 888 379 1,16,630 1,219 1,15,411 1,14,136 3,60,000 -
4 36,000 - 36,000 540 323 863 446 1,48,510 1,612 1,46,898 1,46,048 3,60,000 311 851 465 1,60,757 1,730 1,59,027 1,58,177 3,60,000 -
5 36,000 - 36,000 540 288 828 521 1,88,136 2,065 1,86,071 1,86,071 3,60,000 265 805 552 2,07,800 2,261 2,05,539 2,05,539 3,60,000 -
6 36,000 - 36,000 540 246 786 595 2,28,837 2,517 2,26,320 2,26,320 3,60,000 208 748 641 2,57,982 2,812 2,55,169 2,55,169 3,60,000 -
7 36,000 - 36,000 540 193 733 666 2,70,667 2,969 2,67,699 2,67,699 3,60,000 135 675 731 3,11,545 3,386 3,08,159 3,08,159 3,60,000 -
8 36,000 - 36,000 540 131 671 736 3,13,685 3,419 3,10,266 3,10,266 3,60,000 44 584 822 3,68,752 3,982 3,64,770 3,64,770 3,64,770 -
9 36,000 - 36,000 540 55 595 804 3,57,957 3,869 3,54,088 3,54,088 3,60,000 - 540 926 4,29,810 4,603 4,25,207 4,25,207 4,25,207 -
10 36,000 - 36,000 540 1 541 875 4,03,507 4,319 3,99,188 3,99,188 3,99,188 - 540 1,042 4,94,938 5,248 4,89,690 4,89,690 4,89,690 -
11 36,000 - 36,000 540 - 540 955 4,50,322 4,767 4,45,555 4,45,555 4,45,555 - 540 1,162 5,64,431 5,918 5,58,513 5,58,513 5,58,513 -
12 36,000 - 36,000 540 - 540 972 4,98,524 4,861 4,93,662 4,93,662 4,93,662 - 540 1,207 6,38,704 6,168 6,32,536 6,32,536 6,32,536 -
13 36,000 - 36,000 540 - 540 977 5,48,551 4,885 5,43,665 5,43,665 5,43,665 - 540 1,238 7,18,611 6,337 7,12,275 7,12,275 7,12,275 -
14 36,000 - 36,000 540 - 540 1,044 6,00,478 5,262 5,95,216 5,95,216 5,95,216 - 540 1,354 8,04,586 6,980 7,97,606 7,97,606 7,97,606 -
15 36,000 - 36,000 540 - 540 1,112 6,54,015 5,636 6,48,380 6,48,380 6,48,380 - 540 1,474 8,96,595 7,647 8,88,948 8,88,948 8,88,948 -
Notes:
1. The interest rates of 4 % and 8 % are gross rates i.e. taken before the deduction of Fund Management Charges (FMC).
2. It is assumed that the policy is in-force throughout the term, Acceptance of proposal is subject to Underwriting decision and Mortality charges assumed are for a healthy person.
3. Surrender Value equals the Fund Value at the end of the year minus Discontinuance Charges minus GST on Discontinuance Charges. Surrender value is available on or after 5th
policy anniversary.
4. Currently, the GST applicable is 18.00% and is subject to change in tax rates. The GST on Charges column in this illustration includes GST applicable on FMC, Policy administration
charge and Mortality charges.
6. Net Yield have been calculated after applying all the charges (except GST, mortality charges).
Premium allocation charge is the percentage of premium that would not be utilised to purchase units.
Policy administration charge is the charge of a fixed sum which is applied at the beginning of each policy month by cancelling units for equivalent amount.
Fund management charge is the deduction made from the fund at a stated percentage before the computation of the NAV of the fund.
Mortality charge is the charge recovered for providing life insurance cover.