PROPOSAL FORM/ELECTRONIC PROPOSAL

FORM FOR SINGLE/JOINT LIFE

Linked and Non Linked Individual Life Plans with Declaration of Good Health

For Office use only

Consultant Name & Code: HAREKRUSHNAJENA 01662810
License No: License Expiry Dt: Bancassurance Code:
Company Lead: Lead Reference No: 1-214603813984 Channel Partner Cust Id:
IA / CAO Emp No: IA / CAO Name: Branch Code:
Channel Code: FOS Code: Telecode:

ALL UNIT LINKED POLICIES ARE DIFFERENT FROM TRADITIONAL INSURANCE POLICIES AND ARE SUBJECT TO DIFFERENT RISK FACTORS.
IN UNIT LINKED POLICY THE INVESTMENT RISK IN YOUR CHOSEN INVESTMENT PORTFOLIO IS BORNE BY YOU Photograph of life to be assured*
to be signed across by the life to
be assured
* Not mandatory if life to be
assured is different from the
1) The entire form is to be filled in black ink only by the policyholder. Use CAPITAL letters for information required in boxes with a space between Proposer except if Life to be
assured is minor
words. 2) Any cancellation / alteration is to be signed by the proposed policyholder or life to be assured as appropriate. 3) All information provided here
shall be relied on and should be accurate, complete and true in all respects for processing the proposal quickly. In case you have any doubt whether the
particular information is material or not, please disclose the information. 4) Please attach an extra sheet, wherever additional information is to be given.

Proposer (Primary Life to be Assured)/ Policy Owner Details (Proposer in case of Click 2 Wealth for Premium Waiver Option)
1. Full Name:(Leave a blank Ms. SUBHADRA PANDA
space between First, Middle &
Last Name)
2. Maiden Name:(for married woman
only)

3. Date of Birth (DD/MM/YYYY): 02/07/2001

4. Gender(M/F/Tg): Female
5. Marital Status: Single
6. Nationality: Indian
7. Education: MBA
8. Resident status: Resident Indian
If you are NRI/PIO/OCI, Please attach
appropriate Questionnaire.

Country of Residence:
If NRI/PIO/OCI

Country of Workplace:
If NRI/PIO/OCI

Permanent Country:
9. Do you have an existing HDFC If Yes, please provide Policy NO: Annualised Premium:
Life policy:
10. Does your spouse have an If Yes, please provide Product
existing HDFC Life policy: Name:
11. Are You an employee of HDFC If Yes, please provide Employee Relationship with HDFC Group
Group or Spouse/child of HDFC ID: Employee(if applicable)
Group employee:
12. Correspondence BIRIADIA, BANSADA, BHADRAK, BIRIADIA Bhadrak, Odisha-756129 India
Address:
13. Permanent Address (If BIRIADIA, BANSADA, BHADRAK, BIRIADIA Bhadrak, Odisha-756129 India
different from
correspondence address)/
Overseas residential
address for NRI / PIO / OCI :
14. Mobile: 918144421796
Telephone No(R):
Telephone No(O):
E - mail ID: SUBHADRAP381@GMAIL.COM
Email ID if provided, will be
considered as preferred mode of
communication

15. Preferred language of English

communication:
16. Present Occupation: Salaried
Gross Yearly Income 1,50,000
(INR):
Workplace Name and HEALTH CARE P V T, PATIA, BHUBANESWAR,
Address:
^ if Retired, please provide name of
last organisation

Industry Type (cement, Health

baking, etc.):
Exact Nature of work
(clerical, mechanical,
supervisory job, etc.):
Nature of Occupation Receptionist
(architect, etc.):
17. Income Proof (proposer): Identity Proof (Proposer):
Address Proof Age Proof (Life Assured):
(Proposer):
PAN* (Proposer): FZLPP6058J
18. PAN Photocopy FZLPP6058J
enclosed :(*Submit Form 60 if PAN
is not available)

19. Do you want policy in No E insurance account number:

Demat form?If a policy is requested
in demat form, it will not be given in
physical form and vise versa.

20. Is the Policy holder same Yes

as Life Assured

Date: 05-06-2024 Page 1

 Relationship with Life to Self
be Assured
21. Are you taking the policy No
to primarily protect the
disabled person?
22. Are you a "Politically No
Exposed Person"?
Definition of a Politically Exposed Person: Politically exposed persons are individuals who are or have been entrusted with prominent public functions in a foreign country, their family members
and close relatives; for e.g. Heads of States or of Governments, Senior politicians, Senior government / judicial / military officers,Senior executives of state-owned corporations, Important
politicals party officials, etc.
23. Have you ever been or currently being investigated, charge sheeted, prosecuted or convicted or acquittal or having pending charges in respect of any criminal/civil offences in any
court of law in India or abroad? No
24. Sources of Funds: If Premium & Single Premium Top-ups, if any is equal to or more than INR 1 lakh, please enclose proof of income e.g. ITR

Salaries Business House Property Capital Gains Investments Agriculture Others Total
100% 100%

Details of Secondary Life to be Assured (Life Assured in case of Click 2 Wealth for Premium Waiver Option)
1. Full Name: (Leave a blank space Ms. SUBHADRA PANDA
between First, Middle & Last Name)
2. Maiden Name:(for married woman only)
3. Father/Husband Name: KSHETRABASI PANDA
4. Mother's Maiden Name:
5. Relationship with Primary Life Assured:
6. Date of Birth (DD/MM/YYYY) : 02/07/2001
7. Gender(M/F/Tg): Female
8. Marital Status: Single
9. Nationality: Indian
10. Education: MBA
11. Resident status: Resident Indian
If you are NRI/PIO/OCI, Please attach appropriate
Questionnaire.

Country of Residence:
If you are NRI/PIO/OCI

Country of Workplace:
If you are NRI/PIO/OCI

Permanent Country:
12. Present Occupation: Salaried
13. Gross Yearly Income (INR): 1,50,000
14. Workplace Name and Address: HEALTH CARE P V T, PATIA, BHUBANESWAR,
^ please provide name of last organisation

15. Industry Type (cement, baking, etc.): Health

16. Exact Nature of work (clerical,
mechanical, supervisory job, etc.):
17. Nature of Occupation (architect, etc.): Receptionist
18. Have you ever been or currently being investigated, charge sheeted, prosecuted or convicted or acquittal or having pending charges
in respect of any criminal/civil offences in any court of law in India or abroad? No
19. If Life to Assured is a student/housewife, please provide insurance details regarding parents/husband/siblings.
(Please attach a separate sheet for multiple policies if required.)

Total Sum Assured of all inforce life Policy No. and Name of Company Husband's / Parent's Occupation /
insurance policies Income

Declaration of good health of Primary Life to be Assured/Policy Holder

I hereby declare that, as of the date of this declaration, I/We do not have any history of, have never suffered from or currently suffering from medical conditions such as, but not limited
to, high blood pressure, chest pain, heart attack or any other heart condition; stroke, transient ischemic attack or any other cerebrovascular disease; diabetes or any other endocrinal
disease; kidney disease; HIV / AIDS or AIDS related complex; any cancer or tumor; asthma or any other respiratory disease; any mental or nervous disease; hepatitis or any other liver
disease; blood disorders; digestive and bowel disorders; paraplegia, physical disability or any other disorder of the bones, spine or muscle; any other disease, disorder or disability, not
mentioned above and excluding minor impairment such as common cough or cold. I/We have never undergone or expect to undergo any surgical procedure for any illness, ailment,
disease or disability which is affecting my day to day activities. In the last 5 years, I/We have not received any form of medication for more than 7 consecutive days or been absent
from work for more than 7 days.
I further declare that, as of the date of this declaration, I/We do not engage or intend to engage in any business, sport or occupation of a hazardous nature.

c. For Female Lives: I/We further declare that presently I/We am/are not pregnant or I/We do not have a history in the past of an abortion, miscarriage or caesarean section due to
complications during pregnancy or due to any other cause, I/We have not given birth to a child with any congenital disorder such as Down Syndrome, congenital heart disease, etc and
I/We have not ever had any disease of breast, uterus, cervix, ovaries or any other part of the reproductive system.
d. I/We further declare that, as of the date of this declaration, I/We do not engage or intend to engage in any business, sport or occupation of a hazardous nature. I declare that, I/We
do not have any history of conviction under any criminal proceedings in India or abroad.

Important Note: Any false declaration may be liable for rejection of the proposal form and the contract of insurance shall be treated null & void. It may also lead to rejection of the claim
on death of the life assured.

Date:________________________ Place:_______________________________ Signature/Thumb impression of proposer/ primary/

secondary life assured/Policyholder. Signature should
match with signature on ECS/SI mandate

Nominee Details (To be filled only if Proposer and Life to be assured are same)
Nominee Full Name Date of Birth(DD/ Gender(M/F/Tg) Relationship Contact No % Share
MM/YYYY) with Life to be
Assured
1 Mrs. SHANTI LATA PANDA 10/06/1975 Female Mother 100

Details of Products Applied For

1. Objective of Savings
Insurance:
2. Mode :(for regular / limited Half Yearly
premium paying plan)

3. Premium Payment Limited Pay

Option:
(available only under Click 2

Date: 05-06-2024 Page 2

4. Top-up Option: No ________Top up % Protect 3D Plus )

5a. Product Details:

Product Name Cover type Plan Option Policy Term Premium Sum Modal
(Self/PPH/HUF/ (in years) Payment Assured(in Premium (in
MWPA/Business) INR) INR)
Term(in years)

HDFC Life Saral Jeevan Lump Sum Variant 15 10 4,99,705 15,000

6a. For YoungStar
Udaan, Classic Waiver
Plan Option:
6b. For YoungStar
Super Premium, also
choose Benefit Option:
6c. For Sampoorn
Nivesh, also choose
Benefit Option :
6d. For Classic One,
choose Coverage
Variant :
6e. For Click 2 Wealth,
choose plan option :
6f. For Sanchay
Plus,choose Income
Payout Mode :
6g. For Sanchay Par
Advantage, choose
survival benefit payout
option :
6h. For Sanchay Par
Advantage, also choose
survival benefit payout
frequency :
6i. For Sanchay Par
Advantage, also choose
survival benefit payout
date :
6j. For Click 2 Protect Return of Premium: WoP CI: Accidental Death
Life, choose add on Benefit:
option :
6k. For Click 2 Protect i)Return of Premium:
Super, choose option(s) :
ii)WoP CI:
iii)WoP TPD:
iv)Spouse Cover: If opted, please provide: Spouse Name:
Spouse Sum Assured:
Spouse Date of Birth:
v)Death Benefit as an If opted, choose Instalment Period:
Instalment Option:
Instalment Frequency:
Percentage of Death
Benefit to be Received
as Instalment:
vi)Life Stage Option:
6l. For Click 2 Protect
Super-Life Option
choose Variant opted :
6m. For Click 2 Protect Level Cover Period:
Super-Life Goal Option,
choose:
Amortization Factor:
6n. For Smart Protect
Plan, choose plan
option:
6o. For Smart Protect Level Cover Period
Plan, Decreasing Cover
and Decreasing with
Capital Guarantee
Option choose:
6p. For Sanchay Life ROP
Legacy, choose plan
option
6q. For Sanchay Death Benefit as an If opted, choose Instalment Period
Legacy, choose option Instalment option
Instalment Frequency
Percentage of Death
benefit to be received as
instalment
6r. For Click 2 Achieve - Smart Student Dream Achiever
Choose Plan Option
7. Rider Details: Product Rider Name Coverage Rider Option Rider Rider Premium Pay Rider Modal
(with additional premium) Name Type Policy Term(in years) Sum Premium
Term(in Assured(in (in INR)
years) INR)

HDFC HDFC Life Critical 10 5 4,99,705 384

Life Saral Illness Plus Rider
Jeevan
8. Top-up Premium NIL Top-up Sum Assured NIL Total Premium (INR): 16,128
(INR): (INR):
9. Commencement Backdation Charges
date^: (INR) (if any):
(^only for non linked plan - Has to be within
the same financial year)

10.I wish to opt for Systematic Transfer Plan (STP) No

Source Fund Target Fund Amount Transfer Date

Date: 05-06-2024 Page 3

In case the Transfer Date is not selected, it will be consider
as 1st of the Month.
In order to activate/continue STP, Policyholder has to ensure
that sufficient premiums are allocated in Source Fund.

11. For unit linked plans, kindly indicate % of allocation in below mentioned funds as applicable (please check the fund for the product applied)
Income Balanced Blue chip Opportuni Equity Diversified Bond Conservat Liquid Discovery Equity Bond Plus Secure Sustaina Total
Fund Fund Fund ties Fund Plus Fund Equity Fund ive Fund Fund Fund Advantage Fund Advantage ble Equity
Fund Fund Fund Fund
% % % % % % % % % % % % % % 100%

Details of First Premium Deposit.

Payor Details: Self
Payment Details: Amount in (INR): 16,128
Drawn on (Bank name & branch): ______________________
Cheque / DD No. ______________________ Date: ______________________ Bank A/c No. ______________________

Payout Mode(Choose any one)

Selected mode would be used by the company to make payout(s) to the Proposer. Payout would be in accordance and subject to the terms and conditions of the policy.

1 Account Type: Savings 2 Bank Name: UCO BANK

3 Account 11563211031680 4 Bank Branch: UCO BANK GHANTISWAR
Number:
5 IFSC Code: UCBA0001156

Declaration: 1. In case of non credit to my bank account with/without assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete / incorrect information, I would not hold HDFC Life Insurance Co. Ltd
responsible. 2. In case of NRI/NRE account, cheque will be issued.

Note: Please provide a cancelled copy of your cheque.

Signature of Proposer

Declaration of the Life(s) to be Assured and Proposer / Policy Owner

I/We declare that:

i.I/We have replied to the questions, and have made the statements in respect of the matters sought for, in the proposal Form/Electronic proposal form ("Proposal Form") and I
understand and agree that the replies given and statements/declarations made in the Proposal Form together with any documents submitted by me/us for processing my/our
application for insurance shall be the basis of the contract between me/us and HDFC Life Insurance Company Limited ("the Company"). All documents submitted by me/us along with
this Proposal Form are authentic, valid, and where relevant true copies of originals for the purpose of this Proposal Form have been submitted and I/ we have not withheld any material
fact within my/ our knowledge. ii. I/We understand and agree that in case of misstatement or suppression of material facts the policy contract shall be treated in accordance with the
Sec 45 of Insurance Act,1938 as amended from time to time. iii.I/We shall be bound to notify the Company forthwith, in writing, of any change in my/our health, occupation or income
between the date of this Proposal Form and the date of acceptance of my/our proposal for insurance, as communicated in writing to me/us by the Company. iv. I/We have deposited
the first premium along with this Proposal Form, and the premiums payable under the Policy that may be issued in pursuance of this proposal for insurance, will be paid, strictly in
accordance with the law of the land. Amounts paid, otherwise than from my account shall be paid only if i/we can establish an insurable interest. v. All/any amounts paid/payable
towards the policy will be out of legally declared and assessed sources. Further,all the premiums will be paid in accordance with Prevention of Money Laundering Act 2002 (as
amended from time to time) or any other applicable laws.vi. I/we will provide information as required by the Company, on its own or under any lawful instruction/ order, regarding
sources of funds/utilization/ withdrawals.

I/We agree and understand:

i.That the Company will be on risk in pursuance of this proposal for insurance only after the risk under the Proposal Form is accepted by the Company and such acceptance is
communicated to me/us in writing by the Company. ii.That the Company has the right either to accept or reject my/ our proposal and I undertake that there shall be no costs, claims,
charges being raised by me/ us against the Company thereof. iii. That the Company shall be entitled to retain the premium paid along with the Proposal Form as an interest free initial
deposit to be adjusted against premium payable upon issuance of the Policy. In the event the proposal for insurance is not accepted by the Company the aforesaid deposit shall be
refunded without any interest subject to deductions for medical costs, if any. iv. That the premium payable as well as the sum assured (main as well as additional benefits) may vary
upon assessment of risk by the Company. v.That the Company may seek information from any of my/ our past or present employers/ business associates or from a doctor/medical
examiner / hospital / laboratory / clinic who at any time have attended to me/ us concerning anything which affects my/ our physical or mental health or may seek information from any
insurance office to which an application has been made for insurance on my/ our life. I/ We hereby authorize such parties to furnish information as required by the Company and also
to furnish any documents regarding my/ our employment/business, my/ our health and habits or health and habits of the Life to be Assured (without taking the prior consent of my/ our
family or of any member thereof) as it may require either for the purpose of processing my/ our proposal for insurance or at any time thereafter for any other purpose in relation to the
Policy that may be issued in pursuance of this proposal for insurance vi.In the event of I/we being medically examined, the answers given by me/ us to the medical examiner acting on
behalf of the Company shall be deemed to be incorporated in this proposal for insurance.vii. That the Company may, without any reference to me/us or my family or any member
thereof, furnish any details/ information furnished in this Proposal Form to any judicial or statutory or other authority or to any insurer or reinsurer in connection with the processing of
this proposal for insurance or servicing of this policy. viii. That the Company may contact/ communicate with me/us through postal or courier service, email, telephone, mobile, sms or
VoIP including Whats App. ix. I hereby declare and agree that the above disclosures along with the Statements and the declarations made under the proposal made by me as
Proposer and on behalf of the other/secondary life assured in case of joint life proposals will be the basis of the contract of assurance between us and HDFC Life. If any statement is
found to be untrue or inaccurate or if any fact that might influence the terms of acceptance of this proposal is not disclosed by me in my capacity as Proposer and on behalf of the other/
secondary life assured in case of joint life proposals, the contract shall be treated in accordance with the Sec 45 of Insurance Act,1938 as amended from time to time.x. That I/We have
voluntarily given my/our consent to collect, process, receive, possess, store, deal or handle my/our sensitive personal data or information [as defined in the Information Technology
(Reasonable security practices and procedures and sensitive personal data or information) Rules 2011 as amended from time to time], with third parties/ vendors associated with the
Company for various purposes and outsourced activities related to issuance/servicing/settlement of claim as required under the Policy.

Additional Declaration (Applicable for Health Rider / Product):

i. I/We hereby declare, on my/our behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me/us are true and
complete in all respects to the best of my/ our knowledge and that I/ We am/are authorised to propose on behalf of these other persons. ii. I/We understand that the information
provided by me / us will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy will come into force only after full
payment of the premium chargeable.iii. I/We further declare that I / We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer
after the proposal has been submitted but before communication of the risk acceptance by the company. iv. I/We declare that I/We consent to the company seeking medical
information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer or from any past or present employer concerning anything which
affects the physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /
proposer has been made for the purpose of underwriting the proposal and/or claim settlement. v. I/We authorize the company to share information pertaining to my/our proposal
including the medical records of the insured/proposer for the sole purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory
authority.

Signature/Thumb impression of proposer/ primary/ secondary life assured/Policyholder. Signature should match with signature on ECS/SI mandate

Date: Place:

Mobile:

PLEASE DO NOT SIGN ON THE BLANK PROPOSAL FORM

Declaration of good health for spouse

Date: 05-06-2024 Page 4

Name: DOB: Amount of Insurance:
Within the past 5 years from the date of signing this proposal form, I have neither been hospitalized for, required medication or treatment for, nor consulted a
physician (to include a follow-up visit) due to, or as a result of, any of the following: alcohol or drug abuse, heart or circulatory disorder, stroke, cancer or
leukemia, diabetes, high blood pressure, chronic kidney or liver disease, mental, nervous or neurological disorders, lung disorders, AIDS (acquired immune
deficiency syndrome), ARC (AIDS related complex), or had tests indicating exposure to the AIDS virus.

Yes No Date:____________________ Signature of the spouse

Declaration (If signed in Vernacular language / Thumb impression has been affixed above)

Declaration to be made by a 3rd person where: The life(s) to be assured/proposed policyholder has/have affixed his/her thumb impression; OR the life(s) to be assured/
proposed policyholder has signed in vernacular; OR the life to be assured/proposed policyholder has not filled the application OR/AND The spouse of the life to be
assured/proposed policyholder has affixed his/her thumb impression or signed in vernacular the Declaration of Good Health applicable under Elite Option of Smart
Woman Plan.

I hereby declare that I have explained the contents of this application form to the life(s) to be assured / proposed policyholder in ________________________language and have
truthfully recorded the answers provided to me. I further declare that the life(s) to be assured/proposed policyholder has signed/affixed his/ her thumb impression in my presence.

____________________________________________________________________________________________________ ___________________________________
Name and address of Declarant Signature of Declarant
Occupation of the Declarant
Name and address of Witness Signature of Witness
Occupation of the Witness

Declaration made by life to be assured/proposed policyholder

I/We certify that the contents of the form have been fully explained to me by Mr. / Mrs.:________________________________

_____________________________________________________________________ ______________________________________
Signature/Thumb impression of proposer/ primary/ secondary life assured/Policyholder. Signature should match with Name, Designation & Occupation
signature on ECS/SI mandate

Sections of the Insurance Act 1938 as amended from time to time

Section 41 - Prohibition of rebates: 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.

Section 45 - 1.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, i.e., from the date of
issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later. 2. A policy of life insurance may be
called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud: Provided that 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. 3.Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life
insurance policy on the ground of fraud if the insured can prove that the misstatement of 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 of or suppression of a material fact are within the knowledge of the insurer: Provided that in case of fraud,
the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive. 4.A policy of life insurance may be called in question at any time within three years from the date
of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, 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: Provided that 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 to repudiate the policy of life insurance is based: Provided further that in case of repudiation of the policy on the ground of misstatement
or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal representatives
or nominees or assignees of the insured within a period of ninety days from the date of such repudiation. 5. 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.

Date: 05-06-2024 Page 5