LIFE INSURANCE

ADITYA BIRLA SUN LIFE INSURANCE

COMPANY LTD.

 
COVID-19 (Coronavirus) Exposure Questionnaire
 
Life Insured Name : HARSH KUMAR KAUSHIK

Application Number: BAP1000099

 
Part 1 - Applicable for all applicants

Please answer the following questions with as much detail as possible:

Q No Question Answer

1 Have you experienced any of the following symptoms within the last 14 days?
. Fever (Greater than 38C or 100.4 F)
. Cough
. Shortness of breath
. Malaise (flu-like tiredness)
 YES   ✔ NO
. Rhinorrhoea (mucus discharge from the nose)
. Sore throat
. Gastro-intestinal symptoms such as nausea, vomiting and/or diarrhoea If
yes, to any of these, please indicate which and provide full
information.___NA__

2 Have you been advised to be tested to rule in, or rule out, a diagnosis of novel
coronavirus (SARSCoV-2/COVID-19)? Or, are you awaiting the result of a test which has  YES   ✔ NO
already been submitted for the novel coronavirus (SARS-CoV-2/COVID-19)? __NA

3 Have you ever tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)? If yes,
 YES   ✔ NO
provide the date of positive diagnosis.___ __

4 Are you, or have you been in close contact with anyone who has been quarantined or
who has been diagnosed with novel coronavirus (SARS-CoV-2/COVID-19) ? If yes,  YES   ✔ NO
please provide detailsNA__

5 Have you ever been quarantined due to a possible exposure to novel coronavirus
(SARSCoV2/COVID-19)?  YES   ✔ NO
If yes, please provide dates and locations __

6 Are you currently in good health? ✔  YES   NO

 
7. Travel Declaration:

a. Please provide your travel patterns over the past 14 days:

COUNTRY CITY DATE ARRIVED DATE DEPARTED

 NA  NA  NA  NA

       

       

         

b. Please detail your intended future travel plans for the next 30 days:

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:50 PM
 COUNTRY CITY DATE ARRIVAL INTENDED DURATION

 NA  NA  NA  NA

       

       

         

Part 2: Applicable to Health care workers [ Doctors, Nurses, Paramedics, Pharmacist; Person associated with Healthcare]

Sr No Question Answer

1 Occupation NA

2 Medical Specialty (if applicable) NA

3 Exact nature of duties (including procedural or non-procedural duties) NA

4 Name and address of the healthcare facility or facilities in which you work. NA

5 Name of the Health Authority under which you are registered. NA

Does your healthcare facility have sufficient personal protective equipment (PPE) to
6 NA
provide to its workforce?

         

I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material information that may
influence the assessment or acceptance of this application.
I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any material fact known to me may
invalidate my insurance(s).

 HARSH KUMAR KAUSHIK   Place :_____BILASPUR_______________

Signature of Life Insured / Proposer   Date :____12/27/2020

     

    ABSLI/UW/ COVID/ Marc 2020/Ver1.2

         

         

         

         

 
 

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:50 PM
 Life Insurance Aditya Birla Sun Life Insurance
Company Ltd.
 
COMMON APPLICATION FORM
IN UNIT LINKED POLICIES, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER
CA Ref A:   CA Ref B:  

 
For internal use only Image: photo

Insurance Advisor No.

Broker/Corp. Agent No.   USM Code  
       
Agency Mgr. No.      
Specified Person -      
Officer of CA/Initiator
  Broker Verifier Code  
Code
       
CA Branch Code   Verifier Code  
       
 
APPLICATION FOR INSURANCE ON OWN LIFE / ANOTHER LIFE AGE 18 years & ABOVE
(Please complete the form in BLOCK letters & do not leave any questions unanswered. Use black ink ball pen only)
a) This form to be filled in BLOCK LETTERS WITH A BLACK PEN. b) Any cancellation/alteration in this form to be authenticated by the proposer and all documents submitted
with this Proposal Form must be self attested by the Proposer. c) Insurance contract is based upon utmost good faith between Insurer and the Insured which requires the
Proposer and Life to be Insured to disclose all material facts. d) Please attach an extra sheet, where any additional information needs to be given.
 
1 LIFE to be INSURED Application No.BAP1000099
Do you have an existing Yes   ✔ No
policy with ABSLI?
have you currently applied
for simultaneous policy
If yes, please quote
Policy/Proposal
 
Number/Client ID
Permanent Account
  FMTPK4750H
Number (PAN)
Mobile Number 8319736668
CKYC Number
Title Mr
Full Name   Harsh
    Kumar
    Kaushik
Father/Spouse's Name   Mathura
Date of Birth 11-Jul-2002
Place of Birth
City BILASPUR State CHHATTISGARH
Gender ✔ Male   Female   Transgender
Marital Status ✔ Single   Married   Widowed   Divorced
Mother's Name   Chitrarekha Maiden Name   NA

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 Nationality ✔ Indian   NRI   PIO   FNIO   Others
Are you holding citizenship of any other country?* Yes   ✔ No
If yes please provide
 
country name
Are you a tax resident of
any other country?* Yes   ✔ No

If yes please provide unique

 
tax identification number
Age proof submitted  
       
SSC  ✔  HSC  Graduate    
Qualification
Postgraduate     Professional      Others
✔ Service      Professional     Business 
 Army/Navy/Police     Skilled worker 
Occupation*
 Housewife   Student   Agriculture     
Retired  Others
Name of
  AXIS BANK
Employer/Business
✔ Govt.   Public Ltd.   Private Ltd.   Partnership   Proprietorship    HUF   Trust      
Type of Organization
Society  NGO      Charity   
Nature of Business/Duties   Designation   CLEARK
*Annual Income Rs.   Rs. 2,16,000/-
If not earning, state Parent's
/ Spouse's Annual Income  
Rs.
For Student/Non earning
(Single), state Parents  
Insurance cover Rs.
For House wife, state
 
Spouse Insurance cover Rs.
*Proof is mandatory only where annualized 1 year premium acrossed all policies held by Single individual is > Rs.1,00,000

Are you registered person

under GST Law?   yes      ✔ No   

If yes provide your GST

   
registration number
(Please share the copy of GST registration certificate)    
 
2 PROPOSER
Do you have an existing Yes   No
policy with ABSLI?
have you currently applied for
simultaneous policy
If yes, please quote
   
Permanent Account Number
(PAN)
Mobile Number
CKYC Number  
Title Mr.   Mrs.   Ms.   Dr.
Full Name
   
   
Father/Spouse's Name

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 Date of Birth
Relationship with Life to be
Insured
Gender Male   Female   Transgender
Mother's Name   Maiden Name  
Nationality
Place of Birth
City   State  
Are you holding citizenship of any other country?* Yes   No
If yes please provide country
  India
name
Are you a tax resident of any
other country?* Yes   ✔ No
*If the response to any of the above questions is yes a detailed NRI questionnaire will have to be provided

SSC   HSC  Graduate     Postgraduate    

Qualification
Professional      Others
Service      Professional     Business 
Occupation*  Army/Navy/Police     Skilled worker   Housewife 
 Agriculture      Retired  Others
Name of Employer/Business  

Govt.   Public Ltd.   Private Ltd.   Partnership   Proprietorship    HUF   Trust    

Type of Organization
  Society  NGO      Charity   
Nature of Business/Duties   Designation  
*Annual Income Rs.  
*Proof is mandatory only where annualized 1 year premium acrossed all policies held by Single individual is > Rs.1,00,000

Are you registered person

under GST Law?   yes      No   

If yes provide your GST

   
registration number
(Please share the copy of GST registration certificate)    
 
3 AGE PROOF submitted for the PROPOSER (Please self-attest)

 Birth Certificate    Passport    Driving License    Aadhar Card    School Certificate    Service Record    Others   
 
 
4 MANDATORY DETAILS IN ACCORDANCE WITH ANTI MONEY LAUNDERING GUIDELINES AS PRESCRIBED BY IRDAI
 
Identification Proof of the Proposer (any one)  Aadhar Card    Driving License   PAN Card   Passport     Voter ID
A
card     Others    
Address proof of the Proposer (any one) Proposer (any one)  Passport      Voter's ID card      Driving License   Aadhar
B
Card   Other    
  Address Type   Residential/Business   ✔   Residential     Business     Registered Office     Unspecified
C Income Proof of the Proposer (any one) (mandatory only if total annual policy premiums to ABSLI is Rs. 1 Lac or above)     ITR     Others

D PEP - State whether the Proposer or the Life to be Insured or Nominee are Politically Exposed Person @    Yes   ✔   No
E PAN - Card copy is mandatory along with the application form if the customer pays Rs. 50,000 or more in a financial year ~
@ PEP: "Individuals who are or have been entrusted with prominent public functions domestically or by a foreign country or by an
international organization, for example Heads of State or government, senior politicians, senior government, judicial or military officials,
senior executives of state-owned corporationsand important political party officials OR Family members /close associates who are
related or have business relationships with PEP.".
~ Form 60 is to be filled and signed by the person who is exempted from the requirement of PAN.
 
5 ELECTRONIC INSURANCE ACCOUNT DETAILS of PROPOSER

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 e-INSURANCE A/C details (email address is mandatory) hk321943@GMAIL.COM
✔ Yes No I would like to receive my insurance policy and all the information related to the proposed insurance policy through
insurance repository.
If opted for the above, please submit requisite annexure with the proposer form
If you already have e-insurance A/C number, please provide the same
 National
e-insurance A/C No   Repository Name Insurance-policy
Repository

Would you like to apply. If yes, please mention your preferred Insurance Repository (IR)    KARVY   ✔  NSDL    CDSL  
 CAMS
 
6 ADDRESS for COMMUNICATION with PROPOSER* (all fields are mandatory)
Address 1   H. NO. 420 W. NO. 11
Address 2   ANAND CHOWCK PARSADA
Address 3  
Area  
City/Town/Village   BILASPUR
State   CHHATTISGARH Pin   495223
Proof is mandatory only where annualized 1 year premium acrossed all policies held by Single individual is > Rs. 10,000

Alternate
Tel. No. Res./Office   8319736668  
Mobile
E-mail Address   hk321943@GMAIL.COM

  ✔  English    Hindi    Marathi    Tamil    Telegu  

Your preferred language for communication (select only one)
 Kannada    Bengali    Gujarati    Malayalam    Punjabi
Details where we can send you updates regarding your policy, renewal reminders and ongoing services
Pleases tick on the below box if you wish to receive the renewal reminders, policy statements, ongoing services, various notifications etc. in electronic form

✔  I request you to send my policy documents in electronic form at above email id.
(policy documents will be sent in the physical mode automatically as well).

✔ I request you to send information on my policy regarding renewal reminders, policy statements, ongoing services, various
notifications etc. in electronic form at above email id.
Do you wish to receive the renewal reminders, policy statements, ongoing services, various notifications etc in physical mode
?
✔ Yes   No
# If the address of life insured is different than the proposer, please fill in the details in "Annexure for Life Insured Address" which forms part of proposal.
 
7 PERMANENT ADDRESS for COMMUNICATION with PROPOSER (If different from communication address)
Address 1   H. NO. 420 W. NO. 11
Address 2   ANAND CHOWCK PARSADA
Address 3   IN FRONT OF DR. SANTOSH CLINIC
Area  
City/Town/Village   BILASPUR
State   CHHATTISGARH Pin   495223
 
8 NOMINEE (under Section 39 of Insurance Act, 1938)
Nominee (if Life to be Insured and Proposer are the same person)

Sr. Nominee Relationship with Nomination Share* Nominee Contact

Date of Birth
No. Name Life to be Insured (in %) Details
  1.   ANKIT SINGH  30-Jan-2002  FRIEND  100  
* Sum total of all nomination share should be equal to 100% In case you wish to nominate more nominees, please contact us on toll free number 1-800-270-7000 or write to us
www.adityabirlasunlifeinsurance.com

Appointee (if Nominee is a minor --- Appointee cannot be Life to be Insured)

First Name   9 PURPOSE OF INSURANCE

Risk   ✔ Savings   Childs Education  Childs

Last Name   Marriage  Retirement Planning  Legacy

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 Planning   Others
Date of Birth  
Relationship with Nominee    
10 INSURANCE PLAN DETAILS
  BSLI Guaranteed years or
Plan Name Option   Policy Term   20
Milestone Whole Life

Basic Premium     Pay Term   10 years or

Whole Life
Basic Sum Savings
. 3,46,155/-       years
Assured Date (GSD)
. 100% 150% ABG EMployee/Partner . Yes No
Marriage Mileston
  200% Discount  
ABG Partner
Name
Increasing Sum
Assured 5% 10% (for applicable plans only)

Investment Option A LifeCycle Option Smart Option    Risk Profile     Conservative Moderate Aggressive

  B Return Optimser Option   Frequency     Monthly Weekly  Transfer Date 1st 8th 15th
22nd
  C Systematic Transfer Option
  Transfer Fund          
    (In increments of 5% with minimum of 5% and maximum of 100% in any fund option. Total must be 100%)

  D Self-Managed Option (In increments of 5% with minimum of 5% and maximum of 100% in any fund option. Total must be 100%)
Liquid Plus % Income Advantage % Assure %
Protector % Builder % Enhancer %
Capped Nifty
Creator % Magnifier % %
Index
Asset Allocation % Maximiser % Multiplier %
Value &
Super 20 % Pure Equity % %
Momentum
MNC %        
(Note: For the Segregated Fund Identification Number (SFIN) please refer the product brochure / leaflet or Benefit Illustration. You may also logon to our website
www.adityabirlasunlifeinsurance.com
If the above mentioned values are not legible, missed or mismatch found with application form, then values from Signed Benefit Illustration will be considered)

Riders ABSLI Waiver of Premium (applicable only if Life to be Insured and Proposer are same))
  Name ABSLI   ABSLI ABSLI ABSLI
  Sum Assured Rs.   Rs. Rs. Rs.
Policy Premium Rs. 25,080/- Instalment Premium Rs.2,090/- Mode# A S Q ✔M
          # Payout mode for Annuity Plan

 
11 INSURANCE PLAN DETAILS
For the below mentioned products, Simplfied Application Form is mandatory

Basic Premium
Product Policy Term Premium Paying Instalment Premium Sum Assured
Sr.No /Purchase Price* (in
Name (in years) Term (in years) / Payout* (in Rs.) (in Rs.)
Rs.)

* applicable only in case of ABSLI Immediate Annuity Plan

Note: For every product mentioned in the above table, please provide a duly filled Simplified Application Form. All relevant details of the above mentioned products are captured in the Simplified
Application Form. In case of any discrepancy in the above mentioned details and the ones provided in the Simplified Applicaiton Form, values from the signed benefit illustration will be considered
final.
 
11(a) PREMIUM PAYMENT DETAILS

  Direct Bill    NACH / Direct Debit    Credit Card   ✔  Debit Card    Net Banking  
Payment Method

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
  Salary Deduction    Single Premium    Others  
Payment Mode Single Premium     Yearly     Semi-Yearly     Quarterly      ✔ Monthly  *not eligible for Direct Bill
In case of NACH / Direct Debit, Preferred Draw Date  1st ✔  8th  15th
Initial Premium 2,090/-
 22nd
Top-up Premium Rs. 0 (Incase date is not chosen, policy issuance date will be considered as draw date)

Total Amount paid 2,090/-

(Cheque / DD should be drawn on a local branch of a bank made payable to "ADITYA BIRLA SUN LIFE INSURANCE COMPANY LTD")

Cash (up to Rs. 50,000) Cheque / DD No.   Issuing Bank  

    Date   Payable at (Branch)  
  9-digit MICR code No.      
You are requested to pay cash premium only at ABSLI branches or at authorised collection points and not to the advisor or employee.
The company will not be responsible for any loss in this regard.
Source of Funds ✔ Salary Business Income Others
 
11(b) POLICY PAYOUT DETAILS
✔ NEFT  ABSLI will make payout(s) to the Proposer, in accordance and subject to the terms and conditions
Payout Mode
of the policy.
  KOTAK
Bank Name MAHINDRA Bank Address   BILASPUR
BANK
Account Holder's   HARSH KUMAR ✔ Savings  
Account Type Current
Name KAUSHIK
Account No.   1714302336 9 digit MICR code No.  
IFSC Code   KKBK0006430 (Mandatory)  
Please provide a cancelled blank cheque leaf. In case the cheque does not bear the pre printed name of the account holder /bank account number,we will need photocopy of the
bank statement showing account holder's name, address and account number. The bank statement has to be self attested by customer & attested by ABSLI authorized personnel. In
case of any changes in the above bank details in future , please fill up the payout option form available separately along with copy of cancelled cheque and submit the same at your
nearest branch
 
12 INSURANCE HISTORY OF THE LIFE to be INSURED (Mandatory)
A Is there any concurrent application and any existing insurance on your life for Life / Health / Accident /
Critical Illness and other riders in effect with ABSLI and any other insurer in India or abroad? If Yes, give    Yes   ✔   No
details.

Name of the Insurer Sum Assured (in Rs.)

   
   
   

B Has any of your new proposal/ application for revival/reinstatement for life, accident, medical, health
related insurance or riders or critical illness been refused, withdrawn, declined, postponed or offered with
restricted benefits or with an increased premium or made any claim under any such policy of insurance    Yes   ✔   No
with ABSLI or any other insurer in India or abroad? If Yes, give details.

Name of the Insurer Sum Assured (in Rs.) Reasons

     
 
13 LIFESTYLE, PERSONAL AND MEDICAL DETAILS OF THE LIFE to be INSURED
A PERSONAL DETAILS
  i (a) Height       182.88 cms Weight       63kgs
(b) Is there any weight change during the past
     
one year? If Yes, give details
    Tel. Res. Office Mobile E-mail
B LIFE STYLE INFORMATION
i Do you intend to live or travel outside India for a period of more than 180 days  Yes   ✔   No
  apart from vacation or pleasure?

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 If Yes, submit appropriate questionnaire.
ii Are you involved or do you intend to involve in any hazardous occupation or  Yes   ✔   No
avocation?
  (for e.g. flying other than a fare-paying passenger, diving, mountaineering, working
at heights, underground or offshore, using explosives or any other dangerous
activity) If Yes, submit appropriate questionnaire. _____
Do you consume or have you ever consumed any narcotic substance? If Yes, give  Yes   ✔   No
  iii
details. ___
  iv Do you consume alcohol ? If Yes, give details.  Yes   ✔   No

Have you ever been advised to stop consumption

In the form Quantity per day | week |
Substance of the substance by a Physician? If Yes, specify
  of month
the reason.
       

Do you consume cigarettes/bidis/cigars or used any other tobacco/nicotine products  Yes   ✔   No

  v
in any form? If Yes, when was it last consumed
           Last 12 months  During 13 to 60 months  Before 60 months

Have you ever been advised to stop

In the form consumption
Substance Quantity Per Day No. of years
  of of the substance by a Physician? If Yes,
specify the reason.
          

Has any of your parents, brothers or sisters been diagnosed with any hereditary or chronic
 vi disorder, heart ailment, high blood pressure, cancer, diabetes prior to age 60? If Yes,  Yes   ✔   No
specify details
   None
 

  Age (if living) State of Health If deceased, age at death Cause of Death
Father      48  Accidental
  Mother  43  GOOD    
Brother(s)        
Sister(s)        
 
C Medical History
Have you remained absent from place of work on grounds of health for a continuous period of more than
I)
10 days for reasons other than pregnancy, minor fracture, cold or flu?  Yes   ✔   No

In the past five years, have you ever undergone any surgical operation at a hospital or clinic or undergone
II) any investigations with other than normal or negative results (including X-rays, ECG, blood tests,  Yes   ✔   No
biopsies etc.)?
III) Have you ever sought advice or suffered from any of the following?
(a) Chest pain, low or high blood pressure, high cholesterol, heart attack, heart murmur or other heart
 
disorders?  Yes   ✔   No

(b) Asthma, chronic cough, pneumonia, shortness of breath, tuberculosis (TB) or other respiratory or
 
lung disorders ?  Yes   ✔   No

  (c) Diabetes / elevated blood sugar or sugar in the urine?  Yes   ✔   No

  (d) Ulcer, colitis, chronic diarrhoea, hepatitis or jaundice or other liver or any gastrointestinal disorders?  Yes   ✔   No
  (e) Cancer, tumour, abnormal growth, cyst, enlarged glands or enlarged lymph nodes?  Yes   ✔   No
(f) Dizziness / fainting spells, epilepsy, paralysis, stroke, mental/ psychiatric disorder or any other
  neurological  Yes   ✔   No
disorder?
  (g) Kidney, urinary, bladder, reproductive organ, prostate or any genitourinary disorders?  Yes   ✔   No
  (h) Arthritis, gout or joint pain, muscle disorder, bone fracture or any other musculoskeletal disorders?  Yes   ✔   No
  (i) Disorder of eyes (such as cataract, glaucoma etc.) or throat or ears?  Yes   ✔   No

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
   (j) Any other illness, surgery, ailment or injury which is specifically not mentioned above?  Yes   ✔   No
If any of question is answered as Yes, please submit the appropriate questionnaire.

IV Do you have any congenital anomaly/disorder, physical defects, impairment, deformities and / or any
condition affecting mobility, sightand / or hearing?  Yes   ✔   No

V Do you have any health symptoms or complaints for which a physician has not been consulted or
treatment received?  Yes   ✔   No
(persistent fever, unexplained weight loss, loss of appetite, pain, swelling, etc.)
VI Have you or your spouse received any medical advice, testing or treatment for any sexually transmitted
disease or HIV Infection?  Yes   ✔   No

VII For female lives only:  

  (a) Are you pregnant? If Yes, number of weeks    Yes     No
(b) Have you suffered from or do you have any gynaecological problems or illness related to uterus /
   Yes     No
ovaries or breasts?
     
Provide complete details for all the above questions answered as "Yes"

Date of last
Exact Diagnosis Details of treating Doctor / Surgeon (Name, Date of Diagnosis
Question Consultation
and details of current Qualification, Contact No.) and List of
No. Details and date of hospitalization and
symptoms medication being consumed currently
surgery done
 
14 DECLARATION BY THE LIFE to be INSURED (and PROPOSER if not the Life to be Insured) These declarations would apply to the
application for insurance and the details as contained in the application for insurance duly filled and signed by the Life to be insured and
proposer if not the life to be insured, through this common application form and aforementioned supplemetary application form (s). "

I authorize any medical practitioner, hospital, employer, institution or any other person, to disclose to Aditya Birla Sun Life Insurance Company Limited
("ABSLI") any information relating to my health or employment now or at any time in the future.
I (we) understand and agree that no agent or medical examiner has the authority to waive or vary any stipulations or requirements set by ABSLI. I (we) understand
and agree that the statements and answers given by me (us) during the medical examination (if any) to the medical examiner acting on behalf of ABSLI and any other
documents, medical reports and financial reports required in this application and simplified application (s) for insurance and addendum, if any, shall be deemed to be
incorporated in this application.
I (we) agree and consent to ABSLI for seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/proposer
or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from
any insurance company to which an application for insurance on the life to be assured/proposer has been made and any other authorities as may be required for the
purpose of underwriting the proposal and/or claim settlement.
I (we) confirm that the premiums have not been and will not be generated from proceeds of crime related to any of the offences listed in the Prevention of Money
Laundering Act 2002 and any other applicable statutory provisions as may be in force from time to time.
I (we) have not made any statement to the agent, medical examiner or any other person associated with ABSLI, which in any way modifies the statements and answers
in this application or the simplified applications for insurance and addendum, if any. I (we) are not involved in any criminal proceedings nor have any history of
conviction in India or abroad.
I (we) understand and agree that in case of any fraud or misrepresentation, the policy shall be treated in accordance with Section 45 of the Insurance Act, 1938 as
amended from time to time.
I (we) understand and agree that ABSLI must be notified of any changes in my / our health and circumstances and any application of insurance with any other insurer
in India or abroad logged between the date of this application including the simplified applications for insurance submitted along with this common application and prior
to the acceptance of the risk.
I (we) understand and agree that completion of this application, simplified application (s) submitted for insurance along with this application for insurance and further
addendums, if any, in no way implies that a policy / policies for insurance on the Life to be Insured will be issued by ABSLI. Further, the application for insurance
submitted through this form and along with this application of insurance as simplified application for insurance will be underwritten and processed as separate
applications for insurance and issuance of any one of the application for insurance should not imply the issuance of the other applications of insurance. Each application
as mentioned herein shall be underwritten and reviewed for processing and issuance / rejection separately and independently.
I (we) hereby declare that the contents of this application and the contents of the simplified applications for insurance submitted as a part of this common application
form have been fully explained to me including the significance of the proposed contract of insurance.
I (we) hereby declare that the particulars of the bank account details are true and correct and shall be made applicable for payout(s) if any under this applications
including the simplified application for insurance duly signed and submitted along with this application for insurance. I (we) hereby understand that the payout ( if any)
shall be received via NEFT mode against the details provided from my end in the application form.
I (we) understand and agree that this application form containing my personal information will be shared by ABSLI with its service providers for processing purpose
including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory authority for the
resulting policy only.
I (we) hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and
complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.
I (we) understand that the information provided by me/us will form the basis of the insurance policy, and is subject to the Board approved underwriting policy of the
insurance company and that the policy will come into force only after full receipt of the premium chargeable.

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM
 IA/ Broker/ SP of CA
Date 27-12-2020 Place BILASPUR
Code
           
  HARSH KUMAR KAUSHIK  
Signature or Thumb Impression of the LIFE to be
  Name of IA / Broker / SP of CA Code
INSURED
           
   
Name & Signature or Thumb Impression of the
  Signature of IA / Broker / SP of CA Code
PROPOSER (if not Life to be Insured)
           
VERNACULAR DECLARATION
           
I, ________________________ hereby declare that I have explained the contents of the proposal form to the Life to be
Insured/Proposer in _______________________ language and that I have read out to the answers to the questions dictated by me to
the Life Insured/Proposer and that the Life to be Insured/Proposer has/have put his/her thumb impresssion after fully understanding
the contents thereof.
           
         
        Name & Signature of Declarant
           
I, HARSH KUMAR KAUSHIK confirm that I have been explained the contents of the proposal form in my language and the
information recorded are as
provided by me. I have fully understood the significance of the proposed contract for insurance.
           
     
Signature/Thumb Impression of the PROPOSER/LIFE to be INSURED signing in vernacular
   
language
 
 

Electronically signed by HARSH KUMAR KAUSHIK through One Time Password on 12/27/2020 11:39:49 PM