MAX LIFE INSURANCE COMPANY LIMITED

Regd. Office : 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur,
District Nawanshahr, Punjab- 144533
Head Office: 11th & 12th Floor, DLF Square, Jacaranda Marg, DLF City
Phase-II, Gurugram Haryana, 122 002.

For Unit linked Plans, THE INVESTMENT RISK IN

Unit Linked Proposal
INVESTMENT PORTFOLIO IS BORNE BY THE
Form POLICYHOLDER
PROPOSAL NUMBER: 604249540
SSN
Combo Proposal Number:
GO/CA/Broker Code: X4070 Customer ID: 858104609 Code:
N/A
177400
For Traditional Insurance Plans this proposal is solicited by Axis Bank a Corporate Agent
of Max Life Insurance Co. Ltd.
Do you have a Max Life Insurance Policy or have currently applied simultaneous policies?      If yes give Policy/Proposal number? -(333920304)

Purpose of Insurance: WEALTH CREATION

Objective of Insurance: INDIVIDUAL POLICY
Product Solution: NA Existing Customer: YES

A. Personal Details

Proposer Life to be Insured(if other than proposer)

1. Title MS MR

First SHABEENA SYED

2. Name Middle IQRAR

Last AYESHA AHMED

First CAK SYED

3. Father's / Husband's
Name
Last JUNAID IFTEKHAR AHAMED

4. Date of Birth 23-07-1969 27-10-2000

5. Gender FEMALE MALE

6. Nationality INDIAN INDIAN

6a. Residential country

Residence for Tax purposes in Jurisdiction(s) outside India : NO

(If Yes then FATCA & CRS-Self Certification Form to be mandatorily completed)

7. Marital Status MARRIED SINGLE

8. Education Qualification GRADUATE GRADUATE

9. Relationship with Proposer NA SON

10. Industry Type OTHERS OTHERS

11. Organisation Type NOT APPLICABLE NOT APPLICABLE

12. Occupation/Job Title HOUSEWIFE STUDENT

13. Name of Entity / Employer NA NA

14. Annual Income(Rs.) 800000 500000

15. Is the Life Insured / Proposer / Nominee / Payor a Politically Exposed Person ? : NO

16. Nominee Details     NA

17. Current Residential Address

House No./Apt. Name: #88 2ND CROSS, 28TH MAIN JP

Society Road/Area/Sector: NAGAR 3RD PHASE, BANGALORE
Village/Town:
Landmark: SOUTH, KARNATAKA
City: BANGALORE

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 Pin Code: 560078 State/UT: KARNATAKA Country: INDIA
Mobile No. 1: 9986078582 Mobile No. 2: 9008804967 STD Code: Landline:
Email: SHABEENAIFTEKHAR@YAHOO.CO.IN

18. Permanent Residential Address (Optional)

House No./Apt. Name: #88 2ND CROSS, 28TH MAIN JP

Society Road/Area/Sector: NAGAR 3RD PHASE, BANGALORE
Village/Town:
Landmark:
City: BANGALORE
Pin Code: 560078 State/UT: KARNATAKA Country: INDIA

19. Preferred Mailing Address. Current Residential

20. Do you wish to hold this Policy electronically under e-lnsurance ? NO

B. Coverage Information-Type of Coverage

Coverage Coverage Premium Annual Target Modal GST

a. Base Plan
Term Multiple Payment Term Premium (Rs.) Premium (Rs.) (Rs.)

MAX LIFE FLEXI WEALTH PLUS PLAN 10 10 5 200000 200000 0

Modal Premium without GST* and Cess:

GST* and Applicable Cess: 0 Total Premium Paid: 200000
200000.0
(*GST shall comprise of CGST, SGST/UTGST or IGST (whichever is applicable) including cesses and levies, if any. All applicable taxes, cesses and levies, as per
prevailing laws, shall be borne by you)
You can either opt for one of the below mentioned automated strategies or choose to
INVESTMENT OPTIONS: manage your funds on your own through self-managed Portfolio Strategy. Please
tick if any of the below Strategy is applicable.

i. Systematic Transfer Plan: NO iii. Dynamic Fund Allocation Strategy: NO v. Self-Managed Portfolio Strategy : YES

ii. Lifecycle Based Portfolio Strategy: NO iv. Trigger Based Portfolio Strategy: NO

Growth Diversified High Growth Secure Money Market Dynamic bond

Balanced Secure Conservative
Super equity Growth Fund Plus* II fund
0% 0% 0% 100 % 0% 0% 0% 0% 0% 0%

*Secure Plus fund is not applicable with Self-Managed Portfolio Strategy

2. NEFT Bank A/C Details of Proposer:

All Payouts will be credited to this account through Electronic mode of payment. (This will be applicable at select cities as per facilities/
arrangements of Max Life Insurance).
MICR Code: 560211119 Bank Account Number: 915010030102718

IFSC Code: UTIB0004070 Account Holder's Name: SHABEENA

Type of Bank A/C: Savings Account Bank Name & Branch: Axis Bank KSRTC JP NAGAR BAN KT

Banking Since: 01-07-2015

3. Permanent Account Number (PAN): ABAPI7228P

TDS may be applicable, in accordance with Income Tax Form 60 required: NO
Act 1961, as amended from time to time.
4. Mode of Payment: ANNUAL 5. Renewal premium by: DIRECT DEBIT 6. Source of Funds: HOUSEWIFE

7. Is payor different from proposer/insured ? NO

8. Are you a Max Life Agent or an employee of a Max group company/ Corporate Agents? NO

9. Premium Payment Details

Amount in Words: TWO LAKH

Paid Rs: 200000 Payment by DIRECT DEBIT

Cheque / Draft No. / Online Transaction MAXCRM2114070070121080919 Date: 07-01-2021

Bank Name & Branch:

C. Information of Life Insured

1. Do you have any life or Critical Illness insurance policy issued, pending approval from any other insurance companies or
has your application for Life/Health/Critical illness insurance or its reinstatement ever been offered at modified NO
terms,rejected or postponed ?

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 Life to be
Proposer
Insured

2. In the next 12 months do you intend to travel or reside abroad other than on holiday of less than 4 weeks? NA NO

3. Do you participate or do you intend to participate in any hazardous activities as part of your Occupation/ Sports/
NA NO
Hobby?

4. Have you ever been convicted or are you under investigation for any criminal charges ? NA NO

5. For Female Life Insured YES

Life to be
Proposer
Insured

a. Spouse Occupation SALARIED NA

b. Spouse Annual Income 100000 NA

c. Spouse Insurance Amount 2000000 NA

e. Full Name Prior to Marriage (If there is a name change post marriage): NA NA

f. Are you pregnant? NO NA

6. For Minor Life To Be Insured (Age < 18 yrs.) NO

D. Medical Information

1. Family Details Proposer Life Insured

Has any two (2) or more of your family members (parents & Siblings) ever been diagnosed with diabetes or
NA NA
hypertension or kidney failure or cancer or heart Attack or any Hereditory Disorder before the age of 60 ?

2.

Proposer Life To Be Insured

Height NA 167 cm
Weight NA 70 kg

Life to be
3. Have you ever been investigated, treated or diagnosed with any of the following conditions. Proposer
Insured

i) Diabetes /High blood sugar levels NA NO

ii) Hypertension/ High Blood Pressure, High Cholesterol or Thyroid disorder NA NO

iii) Heart or vascular disorder including chest pain, stroke, heart attack or Angioplasty, CABG or any other heart surgery. NA NO

iv) Breathing or lung disorders including asthma, emphysema, tuberculosis. NA NO

v) Liver or digestive system related disorder including jaundice ,gall bladder, pancreas or Hepatitis B/C. NA NO

vi) Any abnormal growth like tumour,lump,cancer or blood disorder, including anemia or thalassaemia or Sexually transmitted
NA NO
disease ( STD ) including HIV or AIDS.

vii) Any kind of Kidney or bladder disorder, including kidney failure, renal stone, nephritis or prostrate disorder. NA NO

viii) Any neurological or mental health problem like paralysis, multiple sclerosis, Parkinson's, epilepsy, depression or anxiety. NA NO

ix) Muscular-skeletal or joint disorders, including any kind of arthritis, gout, osteoporosis. NA NO

x) Are you having history of any hospitalization, treatment or investigation? NA NO

xi) Have you advised now or in last 5 yrs tests like X-Ray/CT scan/MRI/ Ultrasonography/ ECG/Blood test or any other investigatory
NA NO
or diagnostic tests, or any type of surgery.

Xii) Have you ever been diagnosed with any form of internal or external congenital anomaly or defect i.e. any condition(s) which is
NA NO
present since birth, and which is abnormal with reference to form, structure or position?

Xiii) Have you had any genetic testing before? NA NO

4.Tobacco/Alcohol/Drugs
Do you consume any of the following ?
Consumption:

  Proposer Life Insured

i) Tobacco ( Smoking /Chewing) currently or even occasionally in last 1 year ? NA NO

ii) Alcohol (ML) - Beer/Wine/Hard Liquor. NA NO

iii) Are you taking drugs like Cannabis/Marijuana,Ecstacy,Heroin,LSD,Amphetamines or any other illegal drugs? NA NO

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E. Declaration And Authorisation

1. DECLARATION BY PROPOSER AND LIFE TO BE INSURED

I/We hereby declare that I/We fully understand the meaning and scope of the Proposal form and the questions contained above and I am submitting the completed
proposal form of my/our own volition, and confirm that I/We have not been induced by anyone to make the Proposal. I/We have been explained the nature of
questions and the importance of disclosing all material information.

I/We further declare that all the statements and declarations herein shall be the basis of a contract between me/us and the Company and that I/We have made
complete, true and accurate disclosure of all the facts and circumstances and have not withheld any information that may be relevant to enable the Company to
make an informed decision about the acceptability of the Proposal. I agree that in case of any fraud or misrepresentation, action will be initiated as per Section 45 of
Insurance Act, 1938, as amended from time to time. I/We undertake to notify the Company, forthwith in writing, of any change in any of the statements made in the
Proposal subsequent to the signing of this proposal and before acceptance of risk and issuance of the Policy by the Company. The first and subsequent year
premium will be paid out of legally acquired source of income. I will provide information as and when required by the Company, acting on its own or under any order
or instruction received from Statutory Authorities, as regards to the sources of funds or utilizations or withdrawals. I agree that the Company may provide any
information related to me as available to the Company at any time, to any Statutory Authority in relation to the any laws including the laws governing prevention of
money laundering, applicable in the country. To enable the Company to assess the risk under my/our proposal or for any other purpose in relation to the policy, l/we,
my/our heirs, administrators or executors or assignees hereby authorize my past or present employer(s)/business association/medical practitioners /other agencies
or governmental and/or any regulatory bodies, insurance repositories, CERSAI/ UIDAI, reinsurers / hospitals or diagnostic centres/ other insurance companies/
service providers to disclose and make available to the Company such details/records, as may be requested by the Company. I understand that I have disclosed my
personal information with Max life and I hereby provide consent to Max Life to share, store my information with its authorized service providers for servicing this
policy/proposal such as issuance, underwriting renewal and claims process with respect to this policy as per the regulation applicable from time to time. I/We submit
the mandate to credit My / Our account towards all payments against the above policy and agree and understand that payouts would be processed through
electronic mode of payment and will be affected at select cities as per facilities/ arrangements of Max Life Insurance. I/We authorize Max Life to send all
communications by letter, E-mail, SMS. I/We agree to receive regular reminders, updates / alerts from Max life from time to time.

I/ We authorize Max Life to send all communication by WhatsApp.

OTP Confirmation Date: Place: BANGALORE

2. DECLARATION BY PRINCIPAL OFFICER/AGENT ADVISOR/SPECIFIED PERSON

I MS. PAVITHRA RAI having known the Proposer / Life Insured for a period of do
declare that I have explained the nature of the questions contained in this Proposal form to him / her. I have also explained that the answers to the questions form
the basis of the contract of the Insurance between the Company and the Proposer / Life Insured and if any untrue statement is contained therein and / or any
information that may be relevant to enable the Company make an informed decision, the Company shall have the right to vary the benefits which may be payable
and / or treat the policy voidable at the option of the company subject to section 45 of the Insurance Act, 1938 as amended from time to time. I confirm that to the
best of my knowledge the Life Insured does not suffer from any physical or mental abnormality or handicap or has / had been hospitalised, undergone any surgery
or treatment, or he /she is involved in activities including any hazardous avocation or occupation or any other information material for underwriting this proposal
form, unless expressly stated in this Proposal. I also declare and represent to the Company that I am in full compliance with the regulatory requirements applicable
to agent / corporate agent / specified person / broker prescribed by the Insurance Act 1938, as amended from time to time and any other regulation, circular,
instruction issued by IRDAI from time to time. I confirm that I have verified the identity, current / permanent residential address of the proposer/Insured, the nature of
his/her business and his / her financial status basis the AML Max Life moral hazard checklist.

Is this a Replacement Sale? If yes, I have adequately explained

NO
the consequences of replacement sale to the customer.
Relationship of Principal Officer/Agent Advisor/Specified Person with the
Name of Principal Officer/Agent Advisor/Specified Person
Proposer/Life Insured

Customer MS. PAVITHRA RAI

Signature / OTP Confirmation Date / Thumb Impression /

Specified Person License Number: SP0069342897
Electronic Signature of Proposer:-

Phone No. with STD Code:- 8024253491

We confirm that we have made joint efforts in soliciting the prospect and will be jointly responsible for performing the service related to the policy. We further confirm
that the objective of sharing the commission is not for qualifying for any contest and/or reward & recognition programs of the company.

(Applicable only if more than one Agent Advisors share the commission)

Name(s) of Principal Officer/AA/Spec Person Principal Officer/AA/Spec Person Code % Share

Ms. Pavithra Rai 799921 100

Important Notes: (1) Any payment/s including initial payment accompanying this proposal, cash or by bearer instrument must be made at any of the Company's
General Office only. (2) Crossed cheque or bank drafts must be made in favour of MAX LIFE INSURANCE COMPANY LIMITED ACCOUNT (Proposal No. as
above) maybe handed over to the Agent Advisor. (3} Receipt of the Completed Proposal and initial payment does not create any obligations upon the Company to
underwrite the risk. The Company shall not be liable until it has underwritten the risk and issued the Policy. If the Policy is sent by post it shall be deemed to have
been delivered to and received by you in the ordinary course within 3 (three) days of posting. We draw your attention to Section - 39, Section - 45 and Section - 41
of the Insurance Act 1938 which reads as follows-

Section 39: In case nomination facility is availed, section 39 of the Insurance Act, 1938 as amended from time to time shall apply.

Section 45: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of issuance of policy, from
the date of the Commencement of Risk or Revival of the policy or the date of the rider to the policy, whichever is later. However, Insurer may question the Policy at
any time within three years from the date of issuance of policy, from the date of Commencement of Risk or Revival of the policy or the date of the rider to the policy,
whichever is later, on the ground of fraud, in which case insurer shall inform Proposer/Life Insured/legal representatives in writing specifying the grounds and

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materials on which such decision is based. For other details please referto Section 45 of the Insurance Act, 1938 as amended from time to time.

Section 41: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take 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.

Freelook Clause: We shall inform you by a letter forwarding the policy that you have a period of 15 days (30 days if the policy is sourced through distance
marketing modes)from the date of receipt of the policy document, to review the terms and conditions of the policy, where if you disagree to any of those terms and
conditions, you have the option to return the policy stating the reasons for your objection. You shall be entitled to a refund of the premiums paid, subject only to
deduction of a proportionate risk premium for the period of cover charges of stamp duty paid and the expenses incurred on medical examination of the life insured, if
any.

ULIP_STD_0520_5.1
Date: 7th Jan 2021
Time: 08:22 PM

Additional Declaration:

I hereby authorize AXIS BANK to share my last 6 months bank statement/ One Glance Statement (which includes savings, investments and liabilities in Savings
account, Current account, Deposits, Overdraft account, Demat Accounts, Investments, Insurance, Credit Cards etc. or other similar document and personal KYC
details/documents with Max Life for the purpose of insurance and confirm that the said details can be substantiated with adequate proofs as and when required.

I / we understand that this is not a Fixed Deposit but a life insurance plan. I confirm that this proposal for insurance has being solicited independently and not as
consideration for any other service provided by AXIS BANK.

I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately

I am submitting my Electronic Application of my own volition and have understood the contents of the Electronic Application, and the relevant sales literature
including product features, benefits, applicable charges and am aware of the investment risk under the Policy.

I / We are aware that suitability information has been collected from me/us and recommendation on purchase of life insurance product has been made only basis
such information and any product selected by me/us that differs from such recommendation is on the basis of my/our personal choice. I / we have seen and
understood the benefit illustration shown to me / us on the screen electronically or provided to me / us in physical form, as the case may be. I / we have disclosed
all material information and not withheld any information that may be relevant to enable Max Life to take an informed decision about the acceptability of the
Electronic Application. I also confirm that the information in the Electronic Application, including the state of health and lifestyle habits of the life to be insured is
true and complete. I / we have submitted the confirmation number sent on my mobile number/ email id as a confirmation of the contents of the Electronic
Application and the benefit illustration and agreement to the terms therein.

I/We understand and agree that by submitting the Electronic Application, I / we will be bound by the statements / disclosures of material facts made therein in the
same manner, as if I / we have signed and submitted a written proposal for insurance to the Company and these shall be the basis of a contract between me/us
and the Company. I / we undertake to notify the Company of any change in statements made in the Electronic Application subsequent to its submission and
before acceptance of risk and issuance of the policy by the Company. I / we understand that in case the Company detects any fraud or mis-statement or
suppression of fact material to my/our life expectancy, the Company reserves the right to take appropriate action in accordance with Section 45 of the Insurance
Act.

I / we hereby declare and confirm that details provided in Form 60 attached to this Electronic Application (wherever applicable) are true and correct to the best of
my knowledge and belief. I declare that I do not have a Permanent Account Number and my/ our estimated total income (including income of spouse, minor child
etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which the above
transaction is held will be less than maximum amount not chargeable to tax.

I / we understand that the Company will not be liable unless the premium is received and realized by it within the time period stipulated for the same subject to
underwriting by it. I / we hereby authorize the Company to conduct screening / confirmation of my / our health status through medical examinations on the basis
of which, the Company may accept, decline or offer alternate terms on my proposal. I/we hereby authorize my past and present employer(s) / associate(s) /
medical practitioner(s) / any insurer or any other organization to disclose and make available to the Company my/our information.

I / We have filled the proposal electronically and have received the benefit illustration and filled up proposal form on email and registered mobile OR reviewed it
on tablet / desktop and after observing the said copy, I /we confirm that all the content / information therein is correct to the best of my / our knowledge.

I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately.

I do hereby certify that above stated information regarding the nationality and tax residential status is correct in all respects and may be used for all purposes,
including reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if any, to Max Life within 2 weeks of
occurrence of such change.

Signature / OTP Confirmation Date / Thumb Impression / Electronic Signature of Sales

Signature / OTP Confirmation Date / Thumb Impression / Manager :799921
Electronic Signature of Proposer:
Specified Person License Number: SP0069342897

Phone No. with STD Code :8024253491

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