Common ULIP Proposal Form 290311 print - SBI Life

1 PFPage 1 of 8 EnglishMarathiHindiBengaliGujaratiOriyaT amilTeluguMalayalamKannadaPunjabi 5. PREFERRED LANGUAGE FOR COMMUNICATION 1. ARE YOU AN EXISTING SBI LIFE CUSTOMER?3. SIMULTANEOUS PROPOSALS (IF ANY)1) Proposal No. 2) Proposal No. 3) Proposal No. "IN CASE OF UNIT LINKED INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER To be filled by Sales Representative:AgencyIA/ CIF/ Broker/ CA Name:Instructions for filling up Proposal Form(1). This form is to be filled by the Proposer in BLOCK LETTERS in BLACK INK. In case the Proposer is unable to fill in the form, the person filling in the form must complete the declaration in vernacular section of this form. (2). Please tick a box where appropriate & all Questions should be answered(3). The Proposer must authenticate any cancellation or alterations in this form. ( 4). Insurance is a contract of utmost good faith, which requires all material facts to be disclosed to the Insurer.

2 In case of any doubt as to whether a fact is material or not, the fact should be disclosed. (5). All documents submitted with this Proposal Form must be self attested by the Proposer. (6). Please attach an extra sheet, where ever additional information is to be Do you want to assign this Policy on issuance? Yes NoSourcing Branch Name:Bank/ Broker/ CA Code:If Yes, provide Customer ID/ Policy No.:IA/CIF/SP Code:Sourcing Branch Code:If Yes, please submit relevant documents/annexure with the Proposal FormEmployer Employee Scheme NRII nsurance Advisor s Own LifeState Bank Group StaffIf any option is selected, please submit relevant questionnaire/annexure/supporting documents along with the Proposal Form as applicableHUF2. WHETHER Proposal IS UNDER (please tick relevant option):4. ASSIGNMENT (Not available for Pension Plans)SBI LIFE INSURANCE COMPANY Office: Registered Office: IRDA Registration No. 111"Natraj", M. V. Road, & Western Express Highway Junction, Andheri (East), Mumbai - 400 Bank Bhavan, Madame Cama Road, Nariman Point, Mumbai - 400021.

3 Application NoProduct Code Common ULIP Proposal FORMP roduct Name :_____Plan Option:____ (For SBI Life - Smart Elite, SBI LifeSmart Horizon and wherever applicable)_____ - For Institutional Alliances only: File No. Reference (Pls Specify)OthersCorporate AgencyBrokingBancassuranceDirectCorporat e SolutionsSTAMPSTAMPSTAMPSTAMPSTAMPSTAMPS TAMPSTAMPFOR OFFICE USE ONLYP lease go through the checklist provided at the last page.:Middle Name:Last Name:Passport No.:Valid upto :Maiden Name : Father's Name:First Name6. DETAILS OF PROPOSER/ LIFE TO BE ASSURED/HUF KARTAMr. Ms. Mrs. Gender:Male Female Date of Issue :Country of Residence:Nationality :(for female proposers only):Date of Birth :(DDMMYYYY)(DDMMYYYY)(DDMMYYYY)Page 2 of 8 This page has been intentionally kept PFPage 3 of 8# Important: Incase you have not, please provide your mobile number to help us serve you you do not have a mobile, please provide your landline telephone to the Nominee:Address 8.

4 NOMINEE DETAILS:Mr. Ms. Mrs. (Nomination is not applicable for Minor or HUF Member)Full Name :: Date of Birth :Gender:Male Female Relationship with the ProposerSignature of Appointee:(Please sign in black Ink only)Signature/ Left Hand Thumb APPOINTEE DETAILS: Gender:Male Female Date of Birth :Relationship with the Life to be Assured::Mr. Ms. Mrs.(Applicable in case Nominee is a Minor):Address:Full NameQualifications :Identity Proof:Occupation:Marital Status :Married SingleDriving Licence PAN Card Voters Card Letter from Recognized Public Authority or Public Servant with Photograph verifying the identity & residence BusinessService Construction LabourProfessional Retired HousewifeSelf Employed StudentAgriculturalistFarm LabourOthers (Pls. Specify)Annual Income:`Source of Income:PAN *:Others (Pls. Specify)UrbanI. T. Return/ Assessment Order/ Employers CertRural (Population less than 5000)Income Proof :Domicile:*Please submit self attested copy of PAN Card if Annualised Premium under this Proposal is above ` 1 Lakh or PAN Exemption Form Name & Address of Employer /Business Organisation / Workplace:Specify the exact nature of your duties:Are you exposed to any special hazard associated with your occupation ( chemical factory, mines, explosives, corrosives, combative duties, oil exploration, high sea voyage etc.)

5 Which may render you susceptible to injuries or illnesses?If Yes, please give detailsYesNoPlease indicate whether you or your spouse is working/ retired from State Bank Group Self: PF/ Pension Index/ Employee No.:Spouse: PF/ Pension Index/ Employee No. :If YES, please state:Others (Pls. Specify)Address Proof:Telephone Bill Ration Card Electricity Bill Bank A/C Statement Letter from Recognized Public AuthorityCity/ Village & Taluka/ District: House No. & Bldg/ Society Name: Pin:Road/ Sector & Landmark: #Mobile No.:Tel. No. (Office):Email ID:Aadhar CardAge Proof:PassportOthers (Pls. Specify)Others (Pls. Specify)Communication Address:State:Country: Tel. No. (Home):#YesNoIf yes please give details,Do you have any history of conviction under any criminal proceedings in India or Village & Taluka/ District: House No. & Bldg/ Society Name: Pin:Road/ Sector & Landmark: State:Indian Permanent Address (It is optional and applicable only for NRI) :Aadhar No: (Unique Identification No.)

6 STDPHOONNEO thers (Pls. Specify)SSC CA / MBA / Medicine / Engineer (tick which ever is applicable) Under GraduateHSSC GraduatePost GraduateBirth Cert Passport PAN Card School/College CertDriving LicenceIlliterateIf Total Premium paid by you is 1 lakh and above please submit documents to show the fund source` Are you a Politically Exposed Person (PEP) or a close relative of PEPPEPs are individuals who are or have been entrusted with prominent public functions, heads / ministers of central / state govt., senior politicians, senior govt, judicial or military officials, senior executives of govt. companies, important political party officials, immediate family member of above persons (would include spouse, parents, siblings, children, spouses parents or siblings and close associates of PEPs.) STDPHOONNED ivorcedWidow/Widower Others (Pls. Specify)Address Proof:Telephone Bill Ration Card Electricity Bill Bank A/C Statement Letter from Recognized Public Authority Date of Birth Address :Full Name 7.

7 DETAILS OF MINOR/ LIFE TO BE ASSURED / HUF MEMBER (If different from the Proposer): Mr. Ms. Mrs. Gender:Male Female Relationship with the Proposer::Age Proof:Others (Pls. Specify)Birth Cert Passport PAN Card School/College CertDriving LicenceYesNoYesNoApplication No(DDMMYYYY)(DDMMYYYY)(DDMMYYYY) PFPage 4 of 89. DETAILS OF THE INSURANCE COVER FUND DETAILSFor SBI Life - Smart Performer: Secure Plan Secure and Grow PlanFor SBI Life - Smart Horizon : Please Choose any One from the two options given below: You can choose either Plan A or Plan B (but not both).Min. Allocation to any Plan/ Funds is Nil, Max. 100%Allocation to different Plans/ Funds should be in multiple of 1% .If the allocation percentage is not equal to 100%, the Proposal form will be returnedto define new allocation.*For SBI Life - Smart Horizon - Plan C the total allocation in funds should match with the percentage for Plan C abovePercentage of AllocationPlan APlan C**Total100%(i) Plan A & Plan C:Plan BPlan C**Total100%(ii) Plan B & Plan C:Percentage of AllocationFund Options (allocation % should total to 100%)Plan Name^Please note that SBI Life branches and its sales team are not authorised to collect cash from its customersDraft/ Cheque (`)Drawn on (Bank/ Branch)If Premium is Remitted through Draft/ Cheque, then the same should be issued in favour of 'SBI Life Insurance Co.

8 Proposal Form No. If Premium is Remitted by Electronic Fund Transfer (EFT), through State Bank Group (SBG) Branch, Please provide the Details Below :Bank NameBranch NameBranch CodeDate of EFTA mount ()` DETAILS OF PREMIUM REMITTANCE^: Customer A/c NumberCredit Card ECS (Note : Register for these facilities after receipt of Policy Document)Standing Instructions (Register with your Bank for this facility and ensure that the Bank remits the Renewal Premium to SBI Life on due dates) State Bank ATM (For State Bank ATM customers only, Register at State Bank ATM on receipt of Policy Document)10. MODE OF PAYMENT OF RENEWAL PREMIUM: Online Payment through SBI Life website ( )Direct Remittance (Cheque/ DD) EFT (Available only through SBG Branches)11. DO YOU HAVE ANY OTHER INDIVIDUAL LIFE INSURANCE POLICY OR HAVE YOU APPLIED FOR ONE?YesNo(If Yes,please provide details below)Name of Insurance / ofIssueProduct/Plan/Rider / OptionMedical(Y/N)Yearly Premium (`)Sum Assured ()`Self/Spouse/Parent (Pls.)

9 Specify)Policy StatusRelationAlive/Not AlivePresent Age / Age at DeathHave any of your parents, brothers or sisters died or suffered from any of the diseases / disordersspecified below?**12. FAMILY HISTORY OF THE LIFE TO BE ASSURED:Nature of Disorder**Particulars, including date of diagnosis. If not alive, specify cause of (s)Sister(s)SpouseNo. of Children Sons ( ) Daughters ( )** Heart disease, Hypertension, High Blood Pressure, Diabetes, Stroke, Cancer, Kidney disease, any Hereditary disease, if any other disease, pls. specify. DeclineRated UpInforcePostponeLapsedRejectAdditional sheets with relevant details may be added if space is insufficient AppliedSBI LIFE shall not be responsible for the failure of any of the payment mechanisms, if any. It is the sole responsibility of the Proposer to ensure that the premium is received by SBI LIFE. Is deposit for premium under this Proposal paid by you? Yes No (If answer is NO, please provide required information under Point 19 of the Proposal form) DeclineRated UpInforcePostponeLapsedRejectAppliedImpo rtant: Incase you have not, please provide your mobile number to help us serve you you do not have a mobile, please provide your landline telephone number.

10 Ref: Page 3 Plan Type :Regular Premium Limited Premium Single Premium Premium Frequency: d Yearly Half-yearly Quarterly Monthly Plan/Rider/Option Benefit (Refer respectiveProduct Sales Brochure for riders/options applicable)Policy Term (Yrs.)Premium Paying Term (Yrs.)Basic Plan NameRider/Option NameRider/Option NameModal Premium Payable (`) BASIC PLAN DETAILSSum Assured ()`Premium Payable ()`Rider/Option NameSAMFR ider/Option Premium is inclusive of service tax. The service tax applicable is subject to any change in the tax rateSBI Life - Smart ScholarIndex Fund Top 300 Fund Balanced FundSBI Life - Unit Plus Super Equity Optimiser FundGrowth Fund Money Market FundEquity Fund P/E Managed Fund Bond FundIndex Fund Balanced FundSBI Life - Saral Maha AnandSBI Life - Smart Horizon Plan C*Equity Fund Bond FundIndex Fund Balanced FundSBI Life - Smart EliteEquity Elite Fund IIMoney Market FundP/E Managed Fund Bond FundApplication No Direct Debit of Bank Account or Credit Card)For Monthly mode, 3 months premium to be paid in advance and Renewal Premium Payment through Electronic Clearing System (ECS) or Standing Instructions (where payment is made either by Plan Option : _____Equity FundP/E Managed FundSBI Life - Smart Wealth AssureReturn Guarantee FundBond FundSBI Life - Smart PensionGuaranteed Pension Fund100 Objective of taking this policy :SavingProtectionBothOthers (Pls.)