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CONSENT/DECLARATION FORM
FSC/FSM/AFSM code :
ICICI Pru Group Loan
Plan
Secure
Sum Assured (INR) : Policy Term (yrs):
Premium (INR) :
Annual
One time pay
Other Policy Term (yrs)
Particulars of Life Assured Mr/Mrs : KRISHNA MURTHY GK
Address : 177A Devarahosalli Road, Near Govt Primary School Yelekeri, CHANNAPATTANA, 562160
Date of Birth/Age(yrs) : 0 Gender: Male Loan Account No: 4021060000335037
Loan Type: Mobile No: Email Id:
*Receive communications through phone/email
Details Name Date of Birth Gender Contact No. Relationship to
Nominee -
Appointee -
*If Nominee is less than 18 yrs, Appointee is mandatory. Appointee should be more than 18 yrs of age.
Personal Details of the Life to be Assured - Detailed Medical Questionnaire
SUPPRESSING FACTS OR GIVING WRONG INFORMATION WILL ADVERSELY IMPACT PAYMENT OF YOUR
CLAIM
1. Age Proof:
Driving Licence
Passport
School/ College Certificate
Others
a) Height: (cms) b)Weight: (kgms)
Is the answer to any of the below mentioned medical questions (Q.No.2 to 9)
Yes
NO
2. Do you consume or have consumed any of the following?
smoke more than 10 cigarettes/beedis a day?
consume more than 60ml of alcohol in a day?
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consume any narcotics?
chew more than 30 gms of Tobacco (Gutka) per day?
3. Lifestyle Details of life to be assured:
i. Is your occupation associated with any specific hazard or do you take part in activities or have hobbies that could be
dangerous in any way? (e.g. occupation - chemical factory, mines, explosives, radiation, corrosive chemicals & hobbies -
aviation other than as a fare paying passenger, diving, mountaineering, any form of racing, etc.)
4. Family details of the life to be assured (include parents/sibling) Are any of your family members suffering from/have
suffered from/have died of heart disease, DiabetesMellitus, cancer, or any other hereditary/familial disorder, before 55
years of age? if yes please provide details here_______________________________________________
5. Have you lost weight of 10 kgs or more in the last six months?
6. Do you have any congenital defect/abnormality/physical deformity/handicap?
7. Have you undergone or been advised to undergo any tests/investigations or any surgery or hospitalized for
observation or treatment in past?
8. Did you have any ailment/injury/accident requiring treatment/medication for more than a week or have you availed
leave for more than 5 days on medical grounds in the last two years?
9. Have you ever suffered or been diagnosed with or been treated for any of the following?
Hypertension/High BP/high cholesterol Chest pain/Heart attack/any other heart disease or problem
Undergone angioplasty, bypass surgery, heart surgery Diabetes/High blood sugar/sugar in urine
Asthma, Tuberculosis or any other respiratory disorder Nervous disorders/stroke/paralysis/epilepsy
Any Gastro intestinal disorders like Pancreatitis, colitis etc. Liver disorders/Jaundice/Hepatitis B or C
Genitourinary disorders related to kidney, prostate,urinary system Cancer, Tumour, Growth or cyst of any kind
HIV infection/AIDS or positive test for HIV Any blood disorders like anaemia,Thalassemia etc
Psychiatric or mental disorders Any other disorder not mentioned above,please mention here_______________
10. To be answered by female lives only
a. Have you ever suffered/are suffering from or have undergone any investigation or treatment for any gynecological
complications such as, disorder of cervix, uterus,ovaries, breast, breast lump/cyst etc.?
b. Are you pregnant at present? If yes, please mention number of weeks _________________
COVID-19 Questions:
1. In the last 3 months have you been tested positive for COVID-19? Yes No
2. In the last 3 months have you been self-isolated with symptoms on medical advice? Yes No
3. In the last 1 month have you been advised to self-isolate due to COVID-19 (excluding mandatory government
Yes No
orders to remain at home) ?
4. In the last 1 month have you had a persistent cough, fever, raised temperature or been in contact with an
Yes No
individual suspected or confirmed to have COVID-19?
Payment Authorisation
I do hereby declare that I have received a loan from SBFC Finance Limited ( Master Policyholder ). In order to secure
the said loan I have taken the abovereferenced policy from ICICI Prudential Life Insurance Company Limited. In
consideration of receiving the said loan I hereby authorize ICICI Prudential Life to make payment of Outstanding
Loan Balance amount to Master Policyholder by deducting from the claim proceeds payable on happening of the
contingent event covered by the Group Life Insurance Scheme/ Policy referenced above. In this regard, the remaining
proceeds of the claims due may accordingly be addressed in the name of the nominee. The above declaration and other
details as furnished by me, are true to the best of my knowledge. I hereby authorize ICICI Prudential Life Insurance
Company Limited that in case of difference between the premium received from the applicant and the actual premium
required for sought benefits, the sum assured amount /tenure may get adjusted and the policy shall be issued
accordingly.
__________________________________
Signature/Thumb impression of Witness*
__________________________________
Signature / Thumb Impression of the Insured Member
Name & Address : KRISHNA MURTHY ,177A Devarahosalli Road, Near Govt Primary School Yelekeri
CHANNAPATTANA KARNATAKA 562160
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Date & Place:
Occupation :
*Witness Signature, Address and Occupation is along with signature of Insured Member Signature/Thumb impression of life to
be assured
Payout Mode (Choose any one mode only)
Mode selected would be used by the company to make payout(s). Payout would be in accordance and subject to the terms
and conditions of the policy. Cheque would be used if none of the below Electronic Payout Option is chosen.
1. Mode of deposit :
ECS
Direct Credit (Select Banks only)
NEFT 2. Account Type :
Current
Saving
3. Bank Name : ______________________________________ 4. Bank Branch :
______________________________
5. Account Number :__________________________________ 6. MICR Code
:_______________________________
7. IFSC Code :______________________________
Note:
1. Please provide a cancelled copy of your cheque if any of the above payout option is selected.
2. 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 ICICI Prudential Life Insurance Co. Ltd.
responsible.
3. Further, the Company reserves the right to use any alternative payout option in spite of opting for Direct Credit option.
Signature of Proposer____________________
Declaration & Authorization
I/We declare that I/we have signed the form after understanding its contents and have furnished true and complete information
without withholding any material information. I/We shall immediately notify any change in information, subsequent to signing
this form and before the receipt of the Certificate of Insurance. I/We understand that the terms and conditions including the
benefits are in accordance to applicable laws as amended from time to time. I/We authorize the Company to assess and verify
the health status of the life/lives to be assured through medical examinations including HIV1/2 test. The Company reserves the
right to accept, decline or offer alternate terms on my/our proposal for Life/Health Insurance. I/we authorize the past and
present employer(s)/business associates/medical practitioner(s)/hospital and medical source/any insurer to provide records to
the Company for assessing risk under this proposal and any time thereafter. I/We have understood the terms and conditions of
the Group insurance schemes Rules of SBFC Finance Limited offering Group Loan Secure product and I wish to be a member
of the scheme. I, authorize the Group organizer SBFC Finance Limited to take group insurance on my behalf. In case of fraud
or misrepresentation by me/us, the policy shall be treated in accordance with Section 45 of the Insurance Act, 1938 as amended
from time to time. I/We authorize the Company to mail service communications to my email id as provided. I/We agree and
authorize the Company to verify/share my/our documents/ other information provided herein on confidential basis within
ICICI group and/or with third party agencies or if sought by any public authority.
Date:__/__/__
Place: _________________________________________________
Signature/Thumb impression of Proposer / Life to be Assured______________________
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Declaration to be made by a 3rd person where:
a) The insured member has affixed his/her thumb impression; OR b) The insured member has signed in vernacular;
OR c) The insured member has not filled the application.
I hereby declare that I have explained the contents of this application form to the insured member in ___________ language
and have truthfully recorded the answers provided to me. I further declare that the insured member has signed/affixed his/
her thumb impression in my presence.
Name & Address :______________________________________________________________________
Date & Place : __________________________ Occupation : ______________________________
Signature of Witness____________________
COMP/DOC/NOV/2016/717
Plan
Category Product combination
Gold Death + ADB + TPD
Diamond Death + CI
Platinum Fully Loaded-All options
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