Policy Document–Secure Income Plan

A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

PART A

DHANARAJ KUMARESH LI Address

C/O DHANARAJ M DHANARAJ KUMARESH
NO 41, 1ST BLOCK, NEAR AYYAPPA TEMPLE C/O DHANARAJ M
SIDDARTHANAGAR, JALAHALLI WEST NO 41, 1ST BLOCK, NEAR AYYAPPA TEMPLE
Bangalore North 560015 SIDDARTHANAGAR, JALAHALLI WEST

KARNATAKA
560015
9035607632 Bangalore North
Karnataka
Policy Number 503-5727899
Dear DHANARAJ KUMARESH
Thank you for choosing Bharti AXA Life as your preferred financial protection partner.
I extend a warm welcome to you on behalf of the Bharti AXA Life team. It will always be our endeavour to offer you a
delightful experience. We request you to carefully go through the contents of your Policy to ensure that the features
and benefits are as per your requirements. The Policy consists of the following:
l Policy Schedule
l Policy Document / Bond
l Copies of your proposal form &Illustration of Benefits.
l First Premium Receipt
l Medical reports & any other supplement (if applicable)
l Copy of your acceptance of the Counter Offer (if applicable)
We request you to once again go through the signed proposal form submitted by you enclosed herewith while applying
for the policy. Kindly note that any non-disclosure or incorrect disclosure of information including medical history may
lead to necessary action as per the applicable laws.In case you don’t agree with the terms and conditions of this Policy,
you can withdraw your Policy stating the reason/s within the free look period mentioned below.
Free Look Period: If Policy holder disagrees with any of the terms and conditions of the Policy, there is an option to
return the original Policy along with a letter stating reason/s within 15 days of receipt of the Policy Document. The Policy
will accordingly be cancelled and the Company will refund an amount equal to the Premium paid and may deduct a
proportionate risk premium for the period on cover, the medical expenses incurred by the Company (if any) and the
stamp duty charges. All rights of the Policyholder under this Policy shall stand extinguished immediately on cancellation
of the Policy under the free look option.If the Policy is opted through Insurance Repository (IR), the computation of the
said Free Look Period will be as stated below:- For existing e-Insurance Account: Computation of the said Free Look
Period will commence from the date of delivery of the e mail confirming the credit of the Insurance policy by the IR.For
New e-Insurance Account: If an application for e-Insurance Account accompanies the proposal for insurance, the date of
receipt of the ‘welcome kit’ from the IR with the credentials to log on to the e-Insurance Account(e IA) or the delivery date
of the email confirming the grant of access to the eIA or the delivery date of the email confirming the credit of the
Insurance policy by the IR to the eIA, whichever is later shall be reckoned for the purpose of computation of the free look
period.You need to send the original Policy (the entire booklet) along with a request letter to us at the address
mentioned at the bottom of this letter.We will be pleased to be of any assistance, please call us on our toll-free EASY
ACCESS helpline at 1800-102-4444 or just SMS SERVICE to 56677 and we will be in touch within 24 hours.
Alternatively, you may e-mail us at service@bhartiaxa.com We hope you experience the Bharti AXA Life difference.

Broker Code : 232

Broker Name : AUTHENTIC INSURANCE BROKERS INDIA LTD
Email Id : rlife.tpdcoordinator@authenticbrokers.com
Phone Number : 079-30287503

Your's sincerely, Bharti AXA Life Insurance Company Ltd.

Registered Office: Unit No. 1902, 19th Floor, Parinee Crescenzo, 'G' Block,
Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai
-400051, Maharashtra.IRDA of India Registration Number: 130.

Signature Not Verified Service unit address - Spectrum tower, 3rd Floor, Malad link road, Malad (west),
Mumbai 400064. Maharashtra
Digitally signed by DS BHARTI AXA LIFE
INSURANCE COMPANY LIMITED 2
Date: 2022.07.01 23:05:47 IST
Bharti AXA Life Insurance Company Ltd.
Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground,
Bandra East, Mumbai -400051,Maharashtra.
Service unit address - Spectrum tower, 3rd Floor, Malad link road, Malad (west), Mumbai 400064. Maharashtra

First Premium Receipt Invoice Number - TS2223SL00016259

Invoice Date - 29/06/2022
DHANARAJ KUMARESH
C/O DHANARAJ M Plan
NO 41, 1ST BLOCK, NEAR AYYAPPA TEMPLE Bharti AXA Life Secure Income Plan
SIDDARTHANAGAR, JALAHALLI WEST
Policy Number
Bangalore North 560015 503-5727899
KARNATAKA
9035607632
DKUMARESH12522@GMAIL.COM

GSTIN - ARN Number - LA State - Karnataka

Customer Type - B2C Branch State - Telangana

Policy Details

Sum Assured 1,55,013

Policy Term 20 Years

Issue Date June 29, 2022

Policy Date June 28, 2022

Payment Details

Base Premium (Exclusive of GST) 26789.04

GST Amount
CGST 0.00
SGST 0.00
IGST 1210.91
KERALA CESS (If applicable) 0.00

Total 27999.95

Payment Mode Annual

Next Modal Premium Amount 27,398.09

Next Modal Premium Due Date June 28, 2023

This is to certify that the mentioned premium amount has been received on the Policy Date and adjusted towards premium on
the Issue Date as mentioned above.
Note :
Income tax benefits are as per Income Tax Act, 1961 and are subject to conditions mentioned therein and
amendments made thereto from time to time.
GST shall be applicable as per prevailing tax laws. This is applicable on the total premium
GSTIN: 36AACCB7227P1ZA , SAC: 997132
If the payment has been made other than in cash, this receipt is conditional upon receipt of credit in
Company's account post clearance of the instrument / facility including electronic mode. Further
commencement of risk is subject to receipt of aforesaid payment.
Commencement of risk shall be effective from the date of acceptance of risk.
Insurance is a subject matter of solicitation.
Consolidated Revenue stamp duty paid vide Mudrank No. CSD/338/2020/868/2020 dated February 27, 2020

Nitin Mehta
Chief Customer Officer
 Policy document - Bharti AXA Life Secure Income Plan

Visit us at : www.bhartiaxa.com, IRDA of India Regn No: 130. CIN - U66010MH2005PLC157108

Policy Specifications
Bharti AXA Life Secure Income Plan is a non linked non-participating individual life insurance savings policy. This is a non-participating
Policy i.e. the Policy does not provide for participation in the distribution of surplus or profits that may be declared by the Company.

Policy Details
Policy Holder Date of commencement
DHANARAJ KUMARESH June 28, 2022
of Rider
DHANARAJ KUMARESH
Life Insured

Date of Birth of Life Insured February 12, 1974 Age 48 Years

Gender of Life Insured Male Health Rating Standard

Policy Number 503-5727899 Issue Date June 29, 2022

Policy date/Date of
commencement of Risk June 28, 2022 Maturity Date June 28, 2042
Plan Details
Bharti AXA Life Secure Income Plan -
BASIC PLAN / RIDER (if any) Sum Assured Policy Term/ Rider Term

Bharti AXA Life Secure Income Plan 155013 20

Bharti AXA Life Accidental Death Benefit Rider 50000 10

Guaranteed Monthly Income Date of First Guaranteed Date of Last Guaranteed Monthly
Monthly Income Income

1033 July 28, 2032 June 28, 2042

For Sum Assured on Death: Kindly refer to the Part 1 Section 2A of the Policy

Premium Details
Renewal Premium 27,398.09

Payment Mode Premium Payment Term Payment Method Last Premium Due Date

Annual 10 Years Autopay June 28, 2031

Nominee Details
Name of Nominee & Appointee Age of the Relationship to Nominee/ Date of Birth Percentage
(if applicable) Nominee Life Insured Appointee of the Nominee share

Gayathri 44 1978-04-05 SPOUSE NOMINEE 100.00

Applicable stamp duty deducted vide challan no CSD/271/2022/1035 dated 07 Mar 2022 .
For Bharti AXA Life Insurance Co. Ltd.

Broker Code : 232

Nitin Mehta Broker Name : AUTHENTIC INSURANCE BROKERS INDIA LTD

Date : June 28, 2022 Email Id : rlife.tpdcoordinator@authenticbrokers.com

Place : Mumbai Phone Number : 079-30287503

UIN NO: 130N056V05

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan
Part B
Bharti AXA Life Secure Income Plan is a traditional n) Policy Benefit Period/ Policy Term is the number of
non-participating, limited premium payment policy. Policy Years for which the Policy is in effect,
Non-Participating policy does not participate in the commencing from the Policy Date and ending on the
performance of insurance fund and is not entitled to Maturity Date and is mentioned in the Policy
distribution of Bonus. Annualised Regular Premium payable Specifications.
under the product will be calculated on the basis of policy o) Policy Specifications is the cover page to the Policy
term, age of the life insured, the Guaranteed Income and the containing amongst others, the brief description of the
mode of payment chosen by you as per the proposal form Policy and the Policyholder which forms an integral part
and the policy specifications. of the Policy Document.
1. Definitions: (meaning of technical words used in p) Sum Assured is the minimum amount guaranteed to be
Policy Document) paid on maturity of the policy
a) Age is the Age at last birthday in completed years. q) The Company / Company means Bharti AXA Life
b) Annualized Regular Premium shall be the premium Insurance Company Limited.
amount payable in a year chosen by the policyholder, r) Total Annual Premium is the amount of premium
excluding the taxes, rider premiums, underwriting extra payable in a Policy Year, provided the chosen mode for
premiums and loadings for modal premiums, if any. premium payment is annual.
c) Issue Date is the date of issue of the policy by the s) Total Modal Premium mentioned in the Policy
Company and shall also be the date of commencement Specifications means the premium payable by the
of risk under this Policy which is specified in Policy policyholder on the due dates for payment and in any
Specifications and in case of any attached supplement or case not later than the grace period (30 days for annual/
endorsement, it refers to the date of issue of such semi-annual/quarterly premium payment modes and 15
supplement or endorsement. days for monthly mode), provided the premium payment
d) Limited Premium Payment Policy is a Policy wherein mode chosen by the policyholder is other than annual.
the Premium Payment Term is limited as compared to
t) You/Your/Yours refers to the Policyholder and shall
the Policy Term and where the premium is payable at
mean and include the Nominee, upon the death of the
regular intervals as per the mode of payment chosen by
Life Insured, where the Policyholder and Life Insured is
the policyholder.
the same person.
e) Life Insured is the person named in the Policy The terms defined above shall also act as a reference guide
Specifications whose life is covered under the Policy. to the Policy Document in terms of IRDAI of India
f) Maturity Date is the date on which the Policy Term Circular No. IRDA/LIFE/CIR/GDL/034/01/2014 dated 14
concludes and is shown as such in the Policy January 2014'
Specifications.
g) Nominee is the person nominated under the Policy to PART C
receive the benefits under the Policy in the event of
Benefits Payable
death of the Life Insured before maturity.
1.A Death Benefit
h) Policy means and includes the Policy Document, the
proposal form for insurance submitted by the In case of unfortunate event of death of the Life Insured,
policyholder, the benefit illustration signed by the the following is paid to the nominee, subject to policy
policyholder, the Policy Specifications, the first being in force.
premium receipt , any attached endorsements or Higher Of:
supplements together with all the addendums provided a) Basic Sum Assured plus Guaranteed Additions
by the Company from time to time, the medical accrued till date of death
examiner’s report and any other document/s called for
by the Company and submitted by the policyholder to b) 105% of premiums paid till date of death or
enable it to process the proposal. c) A multiple of Annualized Premium as provided
i) Policyholder is the owner of the Policy whose name is below:
mentioned in the proposal form and may be a person Premium Payment Term Multiple of annualized premium
other than the Life Insured. 5 years 11
j) Policy Date/Date of Commencement of Risk is the 7 years 11
day, month and year the Policy comes into effect and as 10 years 13
shown in the Policy Specifications.
k) Policy Year is measured from the Policy Date and is a Annualized Premium excludes taxes, rider premiums,
period of twelve consecutive calendar months. underwriting extra premiums and loadings for modal
l) Policy Anniversary Date is the date which periodically premiums, if any.
falls after every twelve months starting from the Policy In case of the death of the Life Insured during the grace
Date whilst the Policy is in force. period allowed for payment of due premium, the Death
Benefit, after deducting the unpaid due Premium and any
m) Premium Payment Term means the number of Policy other amount due shall be payable.
Years for which the policyholder is required to pay the
premium.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 1

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

Subject to the exclusions as mentioned in the Policy Docu- Part D

ment, the death benefit shall be payable for death under all
1. Free Look Period
situations (including death during declared or undeclared war,
If you disagree with any of the terms and conditions of the
civil commotion, invasion, terrorism, Naxalite Operation and
Policy, then you have the option to return the original Policy
hostilities.)
Bond along with a letter stating reasons for the objection
within 15 days of receipt of the Policy Bond in case of offline
1.B Survival Benefit (Guaranteed Income)
Policy and within 30 days of receipt of the Policy in case of
Guaranteed Income is a fixed amount which will be payable on
Policy sourced through distance marketing (i.e. online sales).
a monthly basis, starting from the Policy Month falling after
The Policy will accordingly be cancelled and an amount equal
the completion of the Premium Payment term and thereafter
to the Premium paid less stamp duty and medical expenses (if
every subsequent Policy Months, till the end of the Policy
any) incurred by the company will be refunded to the policy-
Term, provided the policy is in force. The Guaranteed Income
holder. All Your rights under this Policy shall stand extin-
will be 8% per annum of the Sum Assured.
guished immediately on the cancellation of the Policy under
the free look option.
1.C Maturity Benefit
If the Policy is opted through Insurance Repository (IR), the
On Maturity of the policy, the Sum Assured will be paid,
computation of the said Free Look Period will be as stated
subject to the policy being in force. Additionally the Guaran-
below:-
teed Additions as accrued will also be payable.
For existing e-Insurance Account: For the purpose of computa-
tion of commencement of free look period, the date of delivery
1.D Payment of Premium
of email confirming the credit of the Insurance Policy by IR
i. You are required to pay Premiums on the due dates and for
shall be reckoned as the starting date of 15 days period.
the amount mentioned in the Policy Schedule.
For New e-Insurance Account: If an application for e-Insur-
ii. You are required to pay Premiums for the entire Premium
ance Account accompanies the proposal for insurance, the date
Payment Term.
of receipt of the ‘welcome kit’ from the IR with the credentials
iii. Premium Payment modes available under the Policy are
to log on to the e-Insurance Account(e IA) or the delivery date
annual, half yearly, quarterly and monthly.
of the email confirming the grant of access to the eIA or the
iv. If the Policyholder discontinues the payment of premiums,
delivery date of the email confirming the credit of the Insur-
the Policy will be treated as Lapsed or Paid-up as per the condi-
ance Policy by the IR to the eIA, whichever is later shall be
tions under Part D Section 3
reckoned for the purpose of computation of the free look
period.
1.E Grace Period
Grace period is the period, which shall be applicable to you to
2. Discontinuance of due premi ums
pay all the unpaid premiums, in case you do not pay Your
premiums as on the Premium Due date. You get Grace Period
2.A Lapsation of Policy
(30 days for annual/ semi-annual/ quarterly premium payment
If the premium is not paid on the due date or during the grace
modes and 15 days for monthly mode) to pay your due premi-
period (during first two years), the Policy shall lapse with
ums, your benefits under the policy remain unaltered during
effect from the date of such unpaid premium (‘lapse date’). The
this period
Company shall notify the policyholder regarding lapse of the
Policy. Lapsation of the Policy shall extinguish all the rights
1.F Guaranteed Addition
and benefits which the policy holder is entitled to under the
A fixed guaranteed addition, declared as a percentage of Sum
Policy.
Assured gets added to your policy each year after the comple-
tion of premium payment term, until maturity of the policy.
2.B Paid Up Policy
These guaranteed additions get paid out either on death or at
If the policy has acquired a surrender value and If you have you
maturity, provided the policy is in force and all due premiums
have not paid due premiums within the grace period, then your
have been paid. This Guaranteed Addition percentage, as
policy will automatically be converted to paid up.
shown in the table below varies as per the policy term chosen.
Once the policy becomes paid up the base benefits will be
Policy term Premium Annual Guaranteed Addition reduced to paid up value which will be payable either on death
Payment Term (applicable after premium or on maturity of the policy. The Guaranteed Income will be
payment term) calculated as a percentage of the paid up value and the reduced
15 years 5 years 7% of Sum Assured guaranteed income will be paid on an annual Basis.
17 years 7 years 8.5% of Sum Assured
The paid up value will be calculated as follows:
20 years 10 years 10% of Sum Assured
Number of Premiums paid X Sum Assured
Premium Payment Term

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 2

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

In case of revival of a paid up policy, the differential amount of 3.B Special Surrender Value:
guaranteed income due (i.e. guaranteed income calculated on The Company may allow surrender values at such other rates
the full Sum Assured less the guaranteed income already paid not less than the Guaranteed Surrender Values specified above.
out on the reduced Paid Up Value), if applicable, shall be paid These rates will be declared by the company from time to time,
to the policyholder. subject to prior approval from IRDAI
The Surrender Value payable will be subject to any statutory or
In case of surrender of a paid up policy, the surrender value any other restrictions as may be applicable. Surrender of the
will be as follows: Surrender Value = Paid Up Value * Policy shall extinguish all rights and benefits of the
Surrender Value Factor Policyholder under the Policy.

3. Surrender Benefit 4. Revival:

The policy acquires a surrender value provided that the The effective date of revival is the date on which the below
Premiums have been paid for at least first two Policy Years. On conditions are satisfied and the risk is accepted by the
surrender of the policy a lump sum amount equal to Company. The revival of the Policy may be on terms different
Guaranteed Surrender Value as defined in below will be paid to from those applicable to the Policy before it lapsed. The revival
the policyholder and the policy gets terminated. The Company will take effect only on it being specifically communicated by
may allow surrender values at such other rates not less than the the Company. The revival rate of interest for FY 19 - 20 is
Guaranteed Surrender Values. These rates will be declared by 8.04%.
the company from time to time, subject to prior approval from
IRDAI A Policy which has lapsed may be revived for full benefits
subject to the following conditions;
3.A Guaranteed Surrender Value: a) The application for revival is made within five (5) years
The Policy acquires a Surrender Value provided that the due from the date of first unpaid premium
Premiums have been paid for at least first two Policy Years . b) Satisfactory evidence of insurability of the Life Insured is
produced,
The guaranteed Surrender Value Factors as a percentage of c) Payment of an amount equal to all unpaid premiums together
premiums paid are as defined in the table below: with interest at such rate as the Company may charge for such
Premium Payment
Revival, as decided by the Company from time to time, subject
5 Years 7 Years 10 Years to prior approval from IRDAI. The differential amount of
Term/ Policy Year
1 0 0 0 guaranteed income due (i.e. guaranteed income calculated on
the full Sum Assured less the guaranteed income already paid
2 30% 30% 30%
out on the reduced Paid Up Value), if applicable, shall be paid
3 35% 35% 35%
to the policyholder;
4 50% 50% 50% d) Terms and conditions as may be specified by the Company
5 50% 50% 50% from time to time.
6 55% 50% 50%
7 60% 55% 55% The effective date of revival is the date on which the above
conditions are met and approved by the Company.
8 65% 55% 55%
9 75% 60% 60%
If the policy is in lapse status: - In case of death of the Life
10 80% 65% 60% Insured during the revival period, no benefit is payable to the
11 85% 75% 65% nominee.
12 95% 80% 65% In case of survival at the end of revival period and if the policy
13 100% 90% 75% is not revived, the policy shall be terminated and no benefit is
payable
14 110% 100% 75%
15 120% 105% 85%
If the policy is in paid up status: - In case of death during the
16 - 115% 95% revival period, Paid up
17 - 125% 105% value will be payable. If the Paid up Policy is not revived
18 - - 115% within the period allowed for revival, the Policy shall continue
19 - - 125% to be in the paid up status and Paid up Value will be paid at
maturity or on Death. Paid Up Value will be calculated in the
20 - - 140%
manner as shown in Part II sub section 3B.
The sum of all Guaranteed Income paid till the year of
surrender shall be deducted from the above mentioned 5. Termination:
Surrender Value. The Policy will terminate on the earliest of the following:
a) The date of confirmation of termination of contract by the

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 3

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

Company against application of the policyholder for surrender 8. Policy alterati ons / Modifications
of the Policy or Only a duly authorized officer of the Company has the power
b) The Maturity Date of the Policy or to effect changes on the Policy/Plan at the request of the
c) Upon Intimation of Death of the Life Insured or Policyholder, subject to the rules of the Company and within
d) The outstanding loan with interest thereon is equal to or the regulatory parameters.
higher than the Surrender Value of the Policy for paid up
policy. 9. Advance Premium
(i) Collection of advance premium shall be allowed within the
6. Suicide: same financial year for the premium due in that financial year.
In case of death due to suicide within 12 months from the date However, where the premium due in one financial year is being
of commencement of risk under the policy or from the date of collected in advance in earlier financial year, the same may be
revival of the policy, as applicable, the nominee or beneficiary collected for a maximum period of three months in advance of
of the policyholder shall be entitled to at least 80% of the total the due date of the premium.
premiums paid till the date of death or the surrender value (ii) The premium so collected in advance shall only be adjusted
available as on the date of death whichever is higher, provided on the due date of the premium.
the policy is in force.

7. Loan:
Loans may be granted by the Company to the Policyholder
provided all Premiums due till date of loan application stand
paid and had acquired Surrender Value. The loan which may
be granted shall always be within the applicable Surrender
Value of the Policy and shall be subject to the terms and
conditions as applicable from time to time:

• The minimum amount of loan for a Policy is Rs.15, 000.

• The maximum amount of loan will not exceed 70% of the

acquired Surrender Value.

• The loan shall carry interest at the rate specified by the

Company at the time of advancing the loan and as may be
modified by the Company from time to time;
PART E
• The Policyholder shall assign the Policy absolutely to and be
Part E is not applicable to this Policy.
held by the Company as security for repayment of the loan and
interest/allied charges thereon;

• The loan shall carry interest at the rate specified by the

Company at the time of advancing the loan. The interest rate in
a policy loan is not fixed and could be reviewed by the
Company on 1st of July every year. This interest rate shall not
exceed sum of (5% and the Base lending rate of State Bank of
India at the time of declaration.) The rate of interest on policy
loan as on 1st July 2018 is 10.40% pa.

• In case the policy is in paid up status, then the outstanding

loan amount together with the interest shall not be equal to or
exceed the Surrender Value of the Policy at any point of time.
In case the outstanding loan amount with interest is greater
than or equal to the surrender value, the policy shall stand
terminated and all future benefits will cease to exist.

• Other terms and conditions as prescribed by the Insurer from

time to time.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 4

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

Part F

10. Fraud And Misrepresentation Nomination: Nomination should be in accordance with

Fraud, Misrepresentation and forfeiture would be dealt with in provisions of sec 39 of the Insurance Act 1938 as amended
accordance with provisions of Sec 45 of the Insurance Act from time to time.
1938 as amended from time to time. [A Leaflet containing the [A Leaflet containing the simplified version of the provisions of
simplified version of the provisions of Section 45 is enclosed in Section 39 is enclosed in appendix – III for reference]
appendix – III for reference]
14. Vesting of Ownership
In case the Life Insured is a minor, the ownership of Policy will
11. Claims automatically vest on the Life Insured on attainment of
For Maturity Benefit: Claimant’s Statement, KYC majority. In case of death of the Policyholder while the Life
Documents and personalized cancelled cheque of the Claimant Insured is a minor, surrender and any other such options
or beneficiary, acceptable to the Company. available under the policy cannot be exercised during the
period of minority of the Life Insured.
For Death Benefit: Original Policy, Death Certificate of
the Life Insured and Claimant’s Statement and KYC
Document of the Claimant or beneficiary, acceptable to the 15. Incorrect information and Non Disclosure
Company and Copy of medical records pertaining to treatment The Policyholder and the Life Insured under the Policy have an
taken by the insured such as admission notes, discharge / death obligation to disclose every fact material for assessment of the
summary, test report etc. available if any. risk in connection with issuing the Policy. However, if any of
the information provided is incomplete or incorrect, the
For Death Benefit (death due to Accident/Unnatural Company reserves the right to vary the benefits, at the time of
death): First Information Report (FIR) and Post Mortem report payment of such benefit or during the term of the Policy.
is required in addition to the documents required for Death Further, if there has/had been non disclosure of a material fact,
Benefit (other than death due to Accident/ natural death) as the Company may treat your Policy as void from inception. In
mentioned above. case fraud or misrepresentation, the policy shall be cancelled
The Company is entitled to call for additional documents, if in immediately by paying the surrender value, subject to the fraud
the opinion of the Company such additional documents are or misrepresentation being established by the insurer in
warranted to process the claim. accordance with Section 45 o f the Insurance Act, 1938.

12. Misstatement of Age and Gender 16. Taxation:

• If the correct Age of the Life Insured is different from that The tax benefits, if any, on the Policy may be available as per
mentioned in the proposal form, the Company will assess the the prevailing provisions of the tax laws in India. If required by
eligibility of the Life Insured for the Policy in accordance with the relevant legislations prevailing from time to time, the
the correct Age of the Life Insured. Company will withhold taxes from the benefits payable under
the Policy. The Company reserves the right to recover statutory
• If on the basis of correct Age, the Life Insured is not eligible levies including applicable tax by way of adjustment of the
for the Policy, the Policy shall be cancelled immediately by premiums paid by the policyholder.
refunding the premium received by the Company under the
Policy as per the provisions of Section 45 of Insurance Act as
amended from time to time. 17. Notices
Any notice to be given to the policyholder under the Policy will
• If the Life Insured is eligible for the Policy as per his / her be issued by post or electronic mail or telephone facsimile
correct Age, then the Company will calculate the applicable transmission to the latest address/es/fax number/email of the
charges basis the correct Age of Life Insured and will policyholder available in the records of the Company.
accordingly adjust the Fund Value / Coverage Sum Assured. Any change in the address of the Policyholder should be
informed to the Company so as to ensure timely
communication of notices and to the correct address.
13. Assignment and Nomination Kindly refer to Part G section 1 of the Bond for intimating
Assignment: Assignment should be in accordance with about the change in existing details.
provisions of sec 38 of the Insurance Act 1938 as amended
from time to time.
[A Leaflet containing the simplified version of the provisions of 18. Currency and Place of Payment
Section 38 is enclosed in appendix – II for reference] All payments to or by the Company will be in Indian rupees
and shall be in accordance with the prevailing Exchange
Control regulations and other relevant laws in force in India.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 5

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

19. Mode of communication byand shall be subject to the laws of India. The parties shall
The Company and the policyholder may exchange submit themselves to the jurisdiction of the competent court/s
communications pertaining to the Policy either through normal of law in India in respect of all matters and disputes which may
correspondence or through electronic mail and the Company arise out of in connection with the Policy document and/ or
shall be within its right to seek clarifications / to carry out the relating to the Policy.
mandates of the policyholder onmerits in accordance with such
communications. While accepting requests / mandate from the 21. Term/s used and its meaning
policyholder through electronic mail, the Company may Any term not otherwise defined in this Policy document shall
stipulate such conditions as deemed fit to give effect to and have the meaning ascribed to it under Policy as defined here in.
comply with the provisions of Information Technology Act If a particular term is not defined or otherwise articulated in the
2000 and/ or such other applicable laws in force from time to Policy, endeavor shall be to impart the natural meaning to the
time. said term in the context in which it is used.

20. Governing Laws & Jurisdiction

The terms and conditions of the Policy shall be governed

Part G

1. Customer Service • Write to our Grievance Officer at:

You can seek clarification or assistance on the Policy from the Bharti AXA Life Insurance Company Ltd.
following: Spectrum tower, 3rd Floor,
• The Agent from whom the Policy was bought Malad link road, Malad (west),
• The Customer Service Representative of The Company at Mumbai 400064. Maharashtra
toll free no. 1800 102 4444
• SMS "SERVICE" to 56677 • Email us at head.customerservice@bharti-axalife.com
• Email: service@bharti-axalife.com
• Mail to: Customer Service You are requested to inform us about your concern (if any)
Bharti AXA Life Insurance Company Ltd. within 8 weeks of receipt of resolution as stated above, failing
Spectrum tower, 3rd Floor, which it will be constructed the complaint is satisfactorily
Malad link road, Malad (west), resolved.
Mumbai 400064. Maharashtra’ If you are not satisfied with the response or do not receive a
response from us within 14 days, you may approach the
2. Grievance Redressal Procedure Grievance Cell of the Insurance Regulatory and Development
Step 1: Inform us about your grievance Authority (IRDA of India) of India on the following contact
In case you have any grievance, you may approach our details:
Grievance Redressal Cell at any of the below-mentioned
helplines: IRDA of India Grievance Call Centre (IGCC) TOLL FREE
NO: 155255 or 18004254732
• Lodge your complaint online at www.bhartiaxa.com Email ID: complaints@irda.gov.in
• Call us at our toll free no. 1800 102 4444
• Email us at complaints.unit@bharti-axalife.com You can also register your complaint online at
• Write to us at: http://www.igms.irda.gov.in/
Registered Office: Address for communication for complaints by paper:
Bharti AXA Life Insurance Company Ltd. Unit No. 1904, Consumer Affairs Department
19th Floor, Parinee Crescenzo 'G' Block, Bandra Kurla Insurance Regulatory and Development Authority of India
Complex, BKC Road, Behind MCA Ground, Bandra East, Survey no.115/1, Financial District,
Mumbai - 400051, Maharashtra’ Nanakramguda, Gachibowli, Hyderabad – 500032
Grievance Redressal Cell, Bharti AXA Life Insurance
Step 3: If you are not satisfied with the resolution provided
Company Ltd., Spectrum tower, 3rd Floor, Malad link
by the company
road, Malad (west), Mumbai 400064. Maharashtra’
In case you are not satisfied with the decision/ resolution of the
• Visit our nearest branch and meet our Grievance Officer who Company, you may approach the Insurance Ombudsman. The
will assist you to redress your grievance/ lodge your complaint. complete list of Insurance Ombusdsman is appended below in
Appendix I or please visit:
Step 2: Tell us if you are not satisfied • www.bhartiaxa.com
In case you are not satisfied with the decision of the above • www.irdaindia.org/ombudsmenlist
office you may contact our Grievance Officer within 8 weeks For informative purpose and for your ready reference, the
of receipt of the resolution communication at any of the relevant clauses of the Insurance Act,1938 are reproduced
below-mentioned helplines: below:

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 6

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

Section 41 of the Insurance Act, 1938: 4) The Central Government or as the case may be, the IRDAI
(1) “No person shall allow or offer to allow, either directly or may, at any time refer any complaint or dispute relating to
indirectly, as an inducement to any person to take out or renew insurance matters specified in sub-rule (1), to the Insurance
or continue an insurance in respect of any kind of risk relating Ombudsman and such complaint or dispute shall be entertained
to lives or property in India, any rebate of the whole or part of by the Insurance Ombudsman and be dealt with as if it is a
the commission payable or any rebate of the premium complaint made under Clause provided herein below.
shown on the policy, nor shall any person taking out or
renewing or continuing a policy accept any rebate, except Section 14 of the Insurance Ombudsman Rules, 2017:
such rebate as may be allowed in accordance with the Manner in which complaint to be made
published prospectus or tables of the insurer: 1) Any person who has a grievance against the Company, may
himself or through his legal heirs, nominee or assignee, make a
(2) Any person making default in complying with the complaint in writing to the Insurance Ombudsman within
provisions of this section shall be liable for a penalty whose territorial jurisdiction the branch or office of the
which may extend to ten lakh rupees.” Company complained against or the residential address or
place of residence of the complainant is located.
Section 45 of Insurance Act, 1938:
Fraud, Misrepresentation and forfeiture would be dealt with in 2) The complaint shall be in writing, duly signed by the
accordance with provisions of Sec 45 of the Insurance Act complainant or through his legal heirs, nominee or assignee
1938 as amended from time to time. [A Leaflet containing the and shall state clearly the name and address of the complainant,
simplified version of the provisions of Section 45 is enclosed in the name of the branch or office of the Company against whom
appendix – IV for reference] the complaint is made, the facts giving rise to the complaint,
supported by documents, the nature and extent of the loss
Section 13 of the Insurance Ombudsman Rules, 2017: caused to the complainant and the relief sought from the
Duties and Powers of Insurance Ombudsman Insurance Ombudsman.
1) The Ombudsman shall receive and consider complaints or
disputes relating to - 3) No complaint to the Insurance Ombudsman shall lie unless -

a) Delay in settlement of claims, beyond the time specified in a. the complainant makes a written representation to the
the regulations, framed under the Insurance Regulatory and Company named in the complaint and -
Development Authority of India Act, 1999;
b) Any partial or total repudiation of claims by the Company; i. either the Company had rejected the complaint; or
c) Disputes over premium paid or payable in terms of insurance ii. the complainant had not received any reply within a period
policy; of one month after the Company received his representation; or
d) Misrepresentation of policy terms and conditions at any time iii. the complainant is not satisfied with the reply given to him
in the policy document or policy contract; by the Company;
e) Legal construction of insurance policies in so far as the
dispute relates to claim; b. The complaint is made within one year -
f) Policy servicing related grievances against insurers and their
agents and intermediaries; i. after the order of the Company rejecting the representation is
g) issuance of life insurance policy, general insurance policy received; or
including health insurance policy which is not in conformity ii. after receipt of decision of the Company which is not to the
with the proposal form submitted by the proposer; satisfaction of the complainant;
h) Non-issuance of insurance policy after receipt of premium iii. after expiry of a period of one month from the date of
in life insurance; and sending the written representation to the Company if the
i) any other matter resulting from the violation of provisions of Company fails to furnish reply to the complainant.
the Insurance Act, 1938, as amended from time to time, or the
regulations, circulars, guidelines or instructions issued by the 4) The Ombudsman shall be empowered to condone the delay
IRDAI from time to time or the terms and conditions of the in such cases as he may consider necessary, after calling for
policy contract, in so far as they relate to issues mentioned at objections of the Company against the proposed condonation
clauses (a) to (f). and after recording reasons for condoning the delay and in case
the delay is condoned, the date of condonation of delay shall be
2) The Ombudsman shall act as counselor and mediator deemed to be the date of filing of the complaint, for further
relating to matters specified in sub-rule (1) provided there is proceedings under these rules.
written consent of the parties to the dispute.
5) No complaint before the Insurance Ombudsman shall be
3) The Ombudsman shall be precluded from handling any maintainable on the same subject matter on which proceedings
matter if he is an interested party or having conflict of interest. are pending before or disposed of by any court or consumer
forum or arbitrator.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 7

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

List of Ombudsman
(For the updated list You may refer to IRDA of India website)

Address & Contact Details of Ombudsmen Centres

Office of The Governing Body of Insurance Council
(Monitoring Body for Offices of Insurance Ombudsman)
3rd Floor, Jeevan Seva Annexe, Santacruz(West), Mumbai – 400054.
Tel no: 26106671/6889. Email id: inscoun@gbic.co.in website: www.gbic.co.in
If you have a grievance, approach the grievance cell of Insurance Company first. If complaint is not resolved/ not
satisfied/not responded for 30 days then You can approach The Office of the Insurance Ombudsman (Bimalokpal)
Please visit our website for details to lodge complaint with Ombudsman.

Office of the Ombudsman Contact Details Areas of Jurisdiction

AHMEDABAD Tel.:- 079 - 25501201/02/05/06 Gujarat,

Office of the Insurance Ombudsman, Jeevan Fax: 079 - 27546142 Dadra & Nagar Haveli,
Prakash Building, 6th floor, Tilak Marg, Relief Email: bimalokpal.ahmedabad@ecoi.co.in Daman and Diu
Road, Ahmedabad – 380 001
BENGALURU Tel.: 080 - 26652048 / 26652049 Karnataka
Office of the Insurance Ombudsman, Email: bimalokpal.bengaluru@ecoi.co.in
Jeevan Soudha Building, PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase, BENGALURU – 560 078.
BHOPAL Tel.: 0755 - 2769201 / 2769202 Madhya Pradesh
Office of the Insurance Ombudsman, Fax: 0755 - 2769203 Chattisgarh
Janak Vihar Complex, 2nd Floor, 6, Email: bimalokpal.bhopal@ecoi.co.in
Malviya Nagar, Opp. Airtel Office,
Near New Market, BHOPAL- 462 003.
BHUBANESHWAR Tel.: 0674 - 2596461 /2596455 Orissa
Office of the Insurance Ombudsman, Fax: 0674 - 2596429
62, Forest Park, BHUBANESHWAR-751 009. Email:bimalokpal.bhubaneswar@ecoi.co.in
CHANDIGARH Tel.: 0172 - 2706196 / 2706468 Punjab, Haryana,
Office of the Insurance Ombudsman, S.C.O. Fax: 0172 - 2708274 Himachal Pradesh,
No. 101, 102 & 103, 2nd Floor, Batra Building, Email: bimalokpal.chandigarh@ecoi.co.in Jammu & Kashmir, Chandigarh.
Sector 17 – D, CHANDIGARH-160 017.

CHENNAI Tel.: 044 - 24333668 / 24335284 Tamil Nadu,

Office of the Insurance Ombudsman, Fax: 044 - 24333664 Pondicherry Town and Karaikal
Fatima Akhtar Court, 4th Floor, 453, Email: bimalokpal.chennai@ecoi.co.in (which are part of Pondicherry).
Anna Salai, Teynampet, CHENNAI-600 018.

DELHI - Tel.: 011 - 23239633 / 23237532 Delhi

Office of the Insurance Ombudsman, Fax: 011 - 23230858
2/2 A, Universal Insurance Bldg.,Asaf Ali Email: bimalokpal.delhi@ecoi.co.in
Road, NEW DELHI-110 002.
GUWAHATI Tel.: 0361 - 2132204 / 2132205 Assam, Meghalaya, Manipur,
Office of the Insurance Ombudsman, Jeevan Fax: 0361 - 2732937 Mizoram, Arunachal Pradesh,
Nivesh, 5th Floor, Nr. Panbazar over bridge, Email: bimalokpal.guwahati@ecoi.co.in Nagaland and Tripura.
S.S. Road, GUWAHATI-781 001(ASSAM)

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 8

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

HYDERABAD. Tel.: 040 - 65504123 / 23312122 Andhra Pradesh,

Office of the Insurance Ombudsman, Fax: 040 - 23376599 Telangana,
6-2-46, 1st floor, "Moin Court", Lane Opp. Email: bimalokpal.hyderabad@ecoi.co.in Yanam and
Saleem Function Palace, A. C. Guards, part of Territory of Pondicherry.
Lakdi-Ka-Pool, HYDERABAD-500 004.

JAIPUR Tel.: 0141 - 2740363 Rajasthan

Office of the Insurance Ombudsman, Email: bimalokpal.jaipur@ecoi.co.in
Jeevan Nidhi II, Ground Floor,
Bhawani Singh Marg, JAIPUR – 302005.

ERNAKULAM Tel.: 0484 - 2358759 / 2359338 Kerala,

Office of the Insurance Ombudsman, 2nd Floor, Fax: 0484 - 2359336 Lakshadweep,
Pulinat Bldg., Opp. Cochin Shipyard, M. G. Email: bimalokpal.ernakulam@ecoi.co.in Mahe-a part of Pondicherry
Road, ERNAKULAM-682 015.

KOLKATA Tel.: 033 - 22124339 / 22124340 West Bengal,

Office of the Insurance Ombudsman, Fax : 033 - 22124341 Sikkim,
Hindustan Building. Annexe, 4th Floor, Email: bimalokpal.kolkata@ecoi.co.in Andaman & Nicobar Islands.
4, C.R.Avenue, KOLKATA - 700072
LUCKNOW Tel.: 0522 - 2231330 / 2231331 Districts of Uttar Pradesh:
Office of the Insurance Ombudsman, Fax: 0522 - 2231310 Laitpur, Jhansi, Mahoba, Hamirpur,
6th Floor, Jeevan Bhawan, Phase-II, Email: bimalokpal.lucknow@ecoi.co.in Banda, Chitrakoot, Allahabad,
Nawal Kishore Road, Hazratganj, Mirzapur, Sonbhabdra, Fatehpur,
LUCKNOW-226 001. Pratapgarh, Jaunpur,Varanasi,
Gazipur, Jalaun, Kanpur, Lucknow,
Unnao, Sitapur, Lakhimpur, Bahraich,
Barabanki, Raebareli, Sravasti,
Gonda, Faizabad, Amethi,
Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli,
Ballia, Sidharathnagar.
MUMBAI Tel.: 022 - 26106552 / 26106960 Goa,
Office of the Insurance Ombudsman, Fax: 022 - 26106052 Mumbai Metropolitan Region
3rd Floor, Jeevan Seva Annexe,S.V. Road, Email: bimalokpal.mumbai@ecoi.co.in excluding Navi Mumbai & Thane.
Santacruz (W), MUMBAI-400 054.

NOIDA Tel.: 0120-2514250 / 2514252 / 2514253 State of Uttaranchal and the following
Office of the Insurance Ombudsman, Email : bimalokpal.noida@ecoi.co.in Districts of Uttar Pradesh:
Bhagwan Sahai Palace, 4th Floor, Agra, Aligarh, Bagpat, Bareilly,
Main Road, Naya Bans, Sector-15, Distt. Bijnor, Budaun, Bulandshehar, Etah,
Gautam Buddh Nagar U.P – 201301. Kanooj, Mainpuri, Mathura, Meerut,
Moradabad, Muzaffarnagar, Oraiyya,
Pilibhit, Etawah, Farrukhabad,
Firozbad, Gautambodhanagar,
Ghaziabad, Hardoi, Shahjahanpur,
Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PUNE Tel.: 020-41312555 Maharashtra,
Office of the Insurance Ombudsman, Email: bimalokpal.pune@ecoi.co.in Area of Navi Mumbai and Thane
Jeevan Darshan Bldg., 3rd Floor, C. T.S No.s excluding Mumbai Metropolitan
195 to198, N.C. Kelkar Road, Narayan Peth, Region.
PUNE – 411030.

PATNA Tel.: 0612-2680952 Bihar, Jharkhand.

Office of the Insurance Ombudsman, 1st Floor, Email id: bimalokpal.patna@ecoi.co.in.
Kalpana Arcade Building, Bazar Samiti Road,
Bahadurpur, PATNA – 800006.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 9

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

BEWARE OF SPURIOUS/FRAUD PHONE CALLS!

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of
premiums. Public receiving such phone calls are requested to lodge a police complaint.

Appendix I: Section 38 - Assignment and Transfer of Insurer, any person aggrieved by the refusal may prefer
Insurance Policies a claim to IRDAI within 30 days of receipt of the refusal
Assignment or transfer of a Policy should be in accordance letter from the Insurer.
with Section 38 of the Insurance Act, 1938 as amended from 12. The priority of claims of persons interested in an
time to time. The extant provisions in this regard are as insurance Policy would depend on the date on which the
follows: notices of assignment or transfer is delivered to the
01. This Policy may be transferred/assigned, wholly or in insurer; where there are more than one instruments of
part, with or without consideration. transfer or assignment, the priority will depend on dates
of delivery of such notices. Any dispute in this regard as
02. An Assignment may be effected in a Policy by an to priority should be referred to Authority.
endorsement upon the Policy itself or by a separate
instrument under notice to the Insurer. 13. Every assignment or transfer shall be deemed to be
absolute assignment or transfer and the assignee or
03. The instrument of assignment should indicate the fact of transferee shall be deemed to be absolute assignee or
transfer or assignment and the reasons for the transferee, except
assignment or transfer, antecedents of the assignee and
terms on which assignment is made. a. where assignment or transfer is subject to terms and
conditions of transfer or assignment OR
04. The assignment must be signed by the transferor or
assignor or duly authorized agent and attested by at least b. where the transfer or assignment is made upon
one witness. condition that
05. The transfer of assignment shall not be operative as i. the proceeds under the Policy shall become
against an insurer until a notice in writing of the transfer payable to Policyholder or nominee(s) in the
or assignment and either the said endorsement or event of assignee or transferee dying before the
instrument itself or copy there of certified to be correct insured OR
by both transferor and transferee or their duly authorized ii. the insured surviving the term of the Policy Such
agents have been delivered to the insurer. conditional assignee will not be entitled to obtain
06. Fee to be paid for assignment or transfer can be specified a loan on Policy or surrender the Policy. This
by the Authority through Regulations. provision will prevail notwithstanding any law or
custom having force of law which is contrary to
07. On receipt of notice with fee, the insurer should Grant a the above position.
written acknowledgement of receipt of notice. Such
notice shall be conclusive evidence against the insurer of 14. In other cases, the insurer shall, subject to terms and
conditions of assignment, recognize the transferee or
duly receiving the notice.
assigne named in the notice as the absolute transferee or
08. If the insurer maintains one or more places of business, assignee and such person
such notices shall be delivered only at the place where a. shall be subject to all liabilities and equities to which
the Policy is being serviced. the transferor or assignor was subject to at the date
09. The insurer may accept or decline to act upon any of transfer or assignment and
transfer or assignment or endorsement, if it has b. may institute any proceedings in relation to the
sufficient reasons to believe that it is Policy
a. not bonafide or c. obtain loan under the Policy or surrender the Policy
b. not in the interest of the Policyholder or without obtaining the consent of the transferor or
c. not in public interest or assignor or making him a party to the proceedings
d. is for the purpose of trading of the insurance Policy. 15. Any rights and remedies of an assignee or transferee of a
life insurance Policy under an assignment or transfer
10. Before refusing to act upon endorsement, the Insurer effected before commencement of the Insurance Laws
should record the reasons in writing and communicate (Amendment), 2014 shall not be affected by this section.
the same in writing to Policyholder within 30 days from [Disclaimer: This is not a comprehensive list of amendments of
the date of Policyholder giving a notice of transfer or Insurance Laws (Amendment), 2014 and only a simplified version
assignment. prepared for general information. Policy Holders are advised to refer
11. In case of refusal to act upon the endorsement by the to Original Insurance Law (Amendment), 2014. ]

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 10

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

Appendix II: Section 39 - Nomination by Policyholder a. parents or

Nomination of a life insurance Policy is as below in b. spouse or
accordance with Section 39 of the Insurance Act, 1938 as c. children or
amended from time to time. The extant provisions in this d. spouse and children
regard are as follows:
e. or any of them
01. The Policyholder of a life insurance on his own life may
nominate a person or persons to whom money secured the nominees are beneficially entitled to the amount
by the Policy shall be paid in the event of his death. payable by the insurer to the Policyholder unless it is
proved that Policyholder could not have conferred such
02. Where the nominee is a minor, the Policyholder may beneficial title on the nominee having regard to the
appoint any person to receive the money secured by the nature of his title.
Policy in the event of Policyholder’s death during the
minority of the nominee. The manner of appointment to 14. If nominee(s) die after the Policyholder but before his
be laid down by the insurer. share of the amount secured under the Policy is paid, the
share of the expired nominee(s) shall be payable to the
03. Nomination can be made at any time before the maturity heirs or legal representative of the nominee or holder of
of the Policy. succession certificate of such nominee(s).
04. Nomination may be incorporated in the text of the Policy 15. The provisions of sub-section 7 and 8 (13 and 14 above)
itself or may be endorsed on the Policy communicated to shall apply to all life insurance policies maturing for
the insurer and can be registered by the insurer in the payment after the commencement of Insurance Laws
records relating to the Policy. (Amendment), 2014 (i.e 26.12.2014).
05. Nomination can be cancelled or changed at any time 16. If Policyholder dies after maturity but the proceeds and
before Policy matures, by an endorsement or a further benefit of the Policy has not been paid to him because of
endorsement or a will as the case may be. his death, his nominee(s) shall be entitled to the
06. A notice in writing of Change or Cancellation of proceeds and benefit of the Policy.
nomination must be delivered to the insurer for the 17. The provisions of Section 39 are not applicable to any
insurer to be liable to such nominee. Otherwise, insurer life insurance Policy to which Section 6 of Married
will not be liable if a bonafide payment is made to the Women’s Property Act, 1874 applies or has at any time
person named in the text of the Policy or in the applied except where before or after Insurance Laws
registered records of the insurer. (Amendment) 2014, a nomination is made in favor of
07. Fee to be paid to the insurer for registering change or spouse or children or spouse and children whether or not
cancellation of a nomination can be specified by the on the face of the Policy it is mentioned that it is made
Authority through Regulations. under Section 39. Where nomination is intended to be
08. On receipt of notice with fee, the insurer should grant a made to spouse or children or spouse and children under
written acknowledgement to the Policyholder of having Section 6 of MWP Act, it should be specifically
registered a nomination or cancellation or change mentioned on the Policy. In such a case only, the
thereof. provisions of Section 39 will not apply.
09. A transfer or assignment made in accordance with [Disclaimer: This is not a comprehensive list of amendments of
Section 38 shall automatically cancel the nomination Insurance Laws (Amendment),2014 and only a simplified version
except in case of assignment to the insurer or other prepared for general information. Policy Holders are advised to
transferee or assignee for purpose of loan or against refer to Original Insurance Law (Amendment), 2014.]
security or its reassignment after repayment. In such
case, the nomination will not get cancelled to the extent Appendix III: Section 45 – Policy shall not be called in
of insurer’s or transferee’s or assignee’s interest in the question on the ground of mis-statement after three years
Policy. The nomination will get revived on repayment of Provisions regarding Policy not being called into question in
the loan. terms of Section 45 of the Insurance Act, 1938, as amended
10. The right of any creditor to be paid out of the proceeds of from time to time.
any Policy of life insurance shall not be affected by the 01. No Policy of Life Insurance shall be called in question
nomination. on any ground whatsoever after expiry of 3 yrs from
11. In case of nomination by Policyholder whose life is a. the date of issuance of Policy or
insured, if the nominees die before the Policyholder, the
proceeds are payable to Policyholder or his heirs or legal b. the date of commencement of risk or
representatives or holder of succession certificate. c. the date of revival of Policy or
12. In case nominee(s) survive the person whose life is d. the date of rider to the Policy
insured, the amount secured by the Policy shall be paid whichever is later.
to such survivor(s).
13. Where the Policyholder whose life is insured
nominates his

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 11

 Policy Document - Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan

02. On the ground of fraud, a Policy of Life Insurance may 09. The insurer can call for proof of age at any time if he is
be called in question within 3 years from entitled to do so and no Policy shall be deemed to be
a. the date of issuance of Policy or called in question merely because the terms of the Policy
are adjusted on subsequent proof of age of life insured.
b. the date of commencement of risk or So, this Section will not be applicable for questioning
c. the date of revival of Policy or age or adjustment based on proof of age submitted
d. the date of rider to the Policy subsequently.
whichever is later. [Disclaimer: This is not a comprehensive list of
For this, the insurer should communicate in writing to amendments of Insurance Laws (Amendment),2014 and
the insured or legal representative or nominee or only a simplified version prepared for general
assignees of insured, as applicable, mentioning the information. Policy Holders are advised to refer to
ground and materials on which such decision is based. Original Insurance Law (Amendment), 2014. ]
03. Fraud means any of the following acts committed by
insured or by his agent, with the intent to deceive the
insurer or to induce the insurer to issue a life insurance
Policy:
a. The suggestion, as a fact of that which is not true and
which the insured does not believe to be true;
b. The active concealment of a fact by the insured
having knowledge or belief of the fact;
c. Any other act fitted to deceive; and
d. Any such act or omission as the law specifically
declares to be fraudulent.
04. Mere silence is not fraud unless, depending on
circumstances of the case, it is the duty of the insured or
his agent keeping silence to speak or silence is in itself
equivalent to speak.
05. No Insurer shall repudiate a life insurance Policy on the
ground of Fraud, if the Insured / beneficiary can prove
that the misstatement was true to the best of his
knowledge and there was no deliberate intention to
suppress the fact or that such mis-statement of or
suppression of material fact are within the knowledge of
the insurer. Onus of disproving is upon the Policyholder,
if alive, or beneficiaries.
06. Life insurance Policy can be called in question within 3
years on the ground that any statement of or suppression
of a fact material to expectancy of life of the insured was
incorrectly made in the proposal or other document basis
which Policy was issued or revived or rider issued. For
this, the insurer should communicate in writing to the
insured or legal representative or nominee or assignees
of insured, as applicable, mentioning the ground and
materials on which decision to repudiate the Policy of
life insurance is based.
07. In case repudiation is on ground of mis-statement and
not on fraud, the premium collected on Policy till the
date of repudiation shall be paid to the insured or legal
representative or nominee or assignees of insured,
within a period of 90 days from the date of repudiation.
08. Fact shall not be considered material unless it has a
direct bearing on the risk undertaken by the insurer. The
onus is on insurer to show that if the insurer had been
aware of the said fact, no life insurance Policy would
have been issued to the insured.

UIN : 130N056V05 Bharti AXA Life Secure Income Plan Page 12

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

PART B

1. Definitions: (meaning of technical words used in document/s called for by the Company and submitted
by the Policyholder to enable the Company to process
Rider Document) request for Rider.
a) Accident is defined a sudden, unforeseen and g) Rider Date / Date of Commencement of Risk is the
involuntary event caused by external and visible means. date of commencement of risk under this Rider and as
b) Accidental Death means death caused by sudden, specified in the Rider Schedule.
violent, unforeseen and involuntary event caused by h) Rider Premium shall be the premium amount payable
external and visible means as revealed by an autopsy in a year, excluding extras as per the rider option/s
provided such death was caused directly by such chosen and is payable according to the mode of payment
Accident and independently of any physical or mental of the Base Policy.
illness within ninety (90) days of the date of Accident.
i) Rider Term is the number of years for which the Rider
c) Age is the Age at last birthday, in completed years. is in-force, commencing from the Rider Date and ending
d) Basic Plan/ Base Policy is the life insurance product on the Expiry Date mentioned in the Rider Schedule.
chosen by the Policyholder out of the various products j) Sum Assured for the purpose of this document is the
offered by the Company. Rider benefit amount as chosen by the Policyholder at
e) Date of Commencement of the Rider is the date of the inception of the Rider.
issue of the Rider by the Company. k) The Company /Company means Bharti AXA Life
f) Rider is an optional Insurance cover which is purchased Insurance Company Limited.
alongwith the Basic Plan. It provides additional benefits l) You/Your/Yours refers to the Policyholder and shall
to the Policyholder/ Life Insured. It is not a standalone also include the Life Insured, where the Policyholder and
document and should be read alongwith Basic Plan. Life Insured are different person/s.
Rider includes the Rider Document, the Rider Schedule, **The terms defined above shall also act as a
any attached endorsements or supplements together with reference guide to the Policy document in terms of
all the addendums provided by the Company from time IRDAI Circular No. IRDA/LIFE/CIR/GDL/034/01/2014
to time, the medical examiner’s report and any other dated 14 January 2014'

PART C
Benefits Payable

1. Death Benefit i. You are required to pay Premiums on the due dates
Accidental Death Benefit Rider can be opted by the and for the amount mentioned in the Policy Schedule.
Policyholder only at the inception of the Basic Plan/ ii. You are required to pay Premiums for the entire
Base Policy. Premium Payment Term.
Subject to the Policy being in force, in the event of death iii. Premium Payment modes available under the Policy
of the Life Insured due to Accident during the Rider are annual, half yearly, quarterly and monthly.
Term, the Company shall pay to the Nominee(s)/ legal iv. If the Policyholder discontinues the payment of
heir(s) of the Policyholder as the case may be, 100% of premiums, the Policy will be treated as Lapsed or Paid-
the Sum Assured. It is clarified that if the Accident up as per the conditions under Part D section 2.
occurs during the Rider Term and the death due to the
said Accident happens after the expiry of the Rider Term 3. Grace Period
(but within 90 days from the date of accident), Death Grace period is the time extended by the Company to
benefit will be payable. facilitate the Policyholder to pay the unpaid premium, in
Maturity/Survival Benefit: There is no maturity or case the premium/s had not been paid as on the due date.
survival benefit payable under this Rider. This Rider The Policyholder gets Grace Period (30 days for
shall automatically cease to exist on the termination of annual/ semi-annual/ quarterly premium payment
the Base Policy as also mentioned in Part D Section 7. modes and 15 days for monthly mode) to pay the
No benefits are payable, if the death is due to the premiums which fell due and the benefits under the
scenarios as mentioned in Part D Section 8 of this Rider. policy remain unaltered during this period.
It is clarified that the Rider Premium becomes payable
2. Payment of Premium along with the Base Policy premium.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |1

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

PART D

1. Free Look Period

• The Company will advise the Policyholder to submit a
If Policyholder disagrees with any of the terms and “Declaration of Good Health” or will advise the
conditions of the Rider, there is an option to return the Policyholder to undergo medical examination (at
original Rider along with a letter stating reason/s within his/her own expense) in the manner prescribed / to be
15 days of receipt of the Rider in case of offline Rider prescribed by the Company as part of the process for
and within 30 days of receipt of the Rider incase the revival.
Rider is sourced through distance marketing (i.e. online Note: The Rider cannot be revived if the Policyholder
sales). The Rider will accordingly be cancelled and the has requested the Company to discontinue the Rider.
Company will refund an amount equal to the Premium
4. Suicide
paid and may deduct a proportionate risk premium for
the period on cover, the medical expenses incurred by In case of death due to suicide within 12 months from
the Company (if any) and the stamp duty charges. All the date of commencement of risk under the policy or
rights under this Rider shall stand extinguished from the date of revival of the policy, as applicable, the
immediately on cancellation of the Rider under the free nominee or beneficiary of the policyholder shall be
look option. entitled to at least 80% of the total premiums paid till
the date of death or the surrender value available as on
If the Rider is opted through Insurance Repository (IR), the date of death whichever is higher, provided the
the computation of the said Free Look Period will be as policy is in force.
stated below:-
5. Claims
For existing e-Insurance Account: Computation of the
said Free Look Period will commence from the date of The Company is entitled to call for the following
delivery of the e mail confirming the credit of the primary documents in support of a claim, at the claim
Insurance policy by the IR. intimation stage under this Rider:
For New e-Insurance Account: If an application for e- • Valid Age Proof ( Driving License in case of Road
Insurance Account accompanies the proposal for Accident)
insurance, the date of receipt of the ‘welcome kit’ from • Copy of Rider (entire book let)
the IR with the credentials to log on to the e- Insurance • Claims intimation form
Account(e IA) or the delivery date of the email • Treating doctor’s certificate duly filled and signed in
confirming the grant of access to the eIA or the delivery original.
date of the email confirming the credit of the Insurance
policy by the IR to the eIA, whichever is later shall be • Copies of Medical records, Discharge card/
reckoned for the purpose of computation of the free look summary and Indoor Case papers.
period. • First Information Report, Panchnama, Inquest report
2. Discontinuance of Rider Premium and Final Investigation Report in case of accidental or
unnatural death.
In case the Base Policy has lapsed due to discontinuance
of premium, the benefits under the Rider shall cease to Prior to processing the claim, the Company is entitled to
exist immediately from the date of such unpaid call for additional documents, if in the opinion of the
premium. Company such additional documents are warranted to
process the claim.
The Policyholder can also opt to discontinue the Rider,
anytime during the Rider Term, however no benefit shall 6. Rider alterations / Modifications
be payable upon the discontinuance of the Rider. Only a duly authorized officer of the Company has the
3. Revival of Rider power to effect changes on the Rider at the request of the
Policyholder, subject to the rules of the Company and
The Rider may be revived subject to the following within the regulatory parameters.
conditions;
7. Expiry of the Rider
• The application for Revival of the Rider benefit is
made within five o (5) years from the date of such Benefits payable under the Rider shall cease to exist, at
unpaid premium and before the termination of Base the occurrence of earliest of the following:
Policy or Expiry of the Rider, whichever is earlier; • On attaining age of 75 years;
• Satisfactory evidence of insurability of the Life • When your Base Policy ceases to exist or lapsed;
Insured; • When the Policyholder discontinues the Rider Premium
An amount equal to all unpaid premiums together with but continues to pay the Base Policy premium;
interest at such rate as the Company may charge for such • When the Rider Premium is not paid within 30 days
revival, as decided by the Company from time to time is from the due date of such unpaid premium;
paid in full;
• All Benefits under the Rider are paid.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |2

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

8. Exclusions • diving or riding or any kind of race; underwater

The Life Insured will not be entitled to any accidental activities involving the use of breathing apparatus or
benefits directly or indirectly due to or caused, not; martial arts; hunting; mountaineering;
occasioned, accelerated or aggravated on account of any parachuting; bungee jumping
of the following: • Intake of Alcohol or Solvent abuse or taking of Drugs,
• Suicide or attempted suicide or self-inflicted injury, narcotics or psychotropic substances unless taken in
whether the Life insured is medically sane or insane. accordance with the lawful directions and prescription
However in case of suicide within one year of issue date of a registered medical practitioner
or one year of latest date of revival of the policy, the • Participation by the insured person in any flying
payout shall be as mentioned in the Part D Section activity, except as a bona fide, fare-paying passenger of
4. a recognized airline on regular routes and on a
• War, terrorism, invasion, act of foreign enemy, scheduled timetable.
hostilities, civil war, martial law, rebellion, 9. Advance Premium
revolution, insurrection, military or usurper power, (i) Collection of advance premium shall be allowed
riot or civil commotion. War means any war whether within the same financial year for the premium due in
declared or not. that financial year. However, where the premium due
• Taking part in any naval , military or air force operation in one financial year is being collected in advance
during peace time in earlier financial year, the same may be collected
• Committing an assault, a criminal offence, an illegal for a maximum period of three months in advance of
activity or any breach of law with criminal intent. the due date of the premium.
The premium so collected in advance shall only be
• Engaging in or taking part in professional sport(s) or adjusted on the due date of the premium.
any hazardous pursuits, including but not limited to,

PART E
Part E is not applicable to this Rider

PART F

1. Fraud And Misrepresentation Sum Assured.

Fraud, Misrepresentation and forfeiture would be dealt 3. Assignment and Nomination
with in accordance with provisions of Section 45 of the Assignment : Assignment shall be in accordance with
Insurance Act 1938 as amended from time to time. the provisions of sec 38 of the Insurance Act 1938 as
[A Leaflet containing the simplified version of the amended from time to time.
provisions of Section 45 is enclosed in appendix – III for [A Leaflet containing the simplified version of
reference] the provisions of Section 38 is enclosed in Appendix
2. Misstatement of Age and Gender – (I) for reference]
• If the correct age of the Life Insured is different from that Nomination: Nomination shall be in accordance with
mentioned in the Application Form, the Company the provisions of sec 39 of the Insurance Act 1938 as
will assess the eligibility of the Life Insured for the amended from time to time.
Policy in accordance with the correct age of the Life [A Leaflet containing the simplified version of the
Insured. provisions of Section 39 is enclosed in Appendix – (II)
• If on the basis of correct age, the Life Insured is not for reference]
eligible for the Policy, the Policy shall be cancelled 4. Taxation
immediately by refunding the Premium received by the The tax benefits, if any, on the Rider may be available as
Company under the Policy as per the provisions of per the prevailing provisions of the tax laws in India. If
Section 45 of Insurance Act 1938 as amended from required by the relevant legislations prevailing from
time to time. time to time, the Company will withhold taxes from the
• If the Life Insured is eligible for the Policy as per his/ benefits payable under the Rider. The Company reserves
her correct age, then the Company will calculate the the right to recover statutory levies including service
applicable charges basis the correct age of Life Insured tax by way of adjustment of the premiums paid by the
and will accordingly adjust the Fund Value / Coverage Policyholder.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |3

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

5. Notices Policyholder on merits in accordance with such

communications. While accepting requests / mandate
Any notice to be given to the Policyholder under the
from the Policyholder through electronic mail, the
Rider will be issued by post or electronic mail or
Company may stipulate such conditions as deemed fit to
telephone facsimile transmission to the latest
give effect to and comply with the provisions of
address/es/fax number/email of the Policyholder
Information Technology Act 2000 and/ or such other
available in the records of the Company.
applicable laws in force from time to time.
Any change in the address of the Policyholder should be
informed to the Company so as to ensure timely 8. Governing Laws & Jurisdiction
communication of notices and to the correct address. The terms and conditions of the Rider document shall be
Kindly refer to Part G section 1 of the Bond for governed by and shall be subject to the laws of India.
intimating about the change in existing details. The parties shall submit themselves to the jurisdiction of
the competent court/s of law in India in respect of all
6. Currency and Place of Payment matters and disputes which may arise out of in
All payments to or by the Company will be in Indian connection with the Rider document and / or relating to
rupees and shall be in accordance with the prevailing the Rider.
Exchange Control regulations and other relevant laws in 9. Term used and its meaning
force in India.
Any term not otherwise defined in this Rider document
7. Mode of communication shall have the meaning ascribed to it under Rider as
The Company and the Policyholder may exchange defined here in Part B (g). If a particular term is not
communications pertaining to the Rider either through defined or otherwise articulated either in the Rider
normal correspondence or through electronic mail and document or under the Rider, endeavor shall be to impart
the Company shall be within its right to seek the natural meaning to the said term in the context in
clarifications / to carry out the mandates of the which it is used.

PART - G

1. Customer Service • Write to us at:

You can seek clarification or assistance on the Grievance Redressal Cell
Rider from the following: Bharti AXA Life Insurance Company Ltd. Spectrum
• The Advisor from whom the Rider was bought Towers, 3rd Floor,
• The Customer Service Representative of The Malad Link Road, Malad (West), Mumbai – 400064.
Company at toll free no. 1800 102 4444 • Visit our nearest branch and meet our Grievance
• SMS "SERVICE" to 56677 Officer who will assist you to redress your grievance/
lodge your complaint.
• Email: service@bharti-axalife.com
Step 2: Tell us if you are not satisfied
• Mail to: Customer Service
In case you are not satisfied with the decision of the
Bharti AXA Life Insurance Company Ltd. Spectrum above office you may contact our Grievance Officer
Towers, 3rd Floor, within 8 weeks of receipt of the resolution
Malad Link Road, Malad (West), Mumbai – 400064. communication at any of the below-mentioned
helplines:
2. Grievance Redressal Procedure • Write to our Grievance Officer at:
Step 1: Inform us about your grievance Bharti AXA Life Insurance Company Ltd. Spectrum
Towers, 3rd Floor,
In case you have any grievance, you may approach
our Grievance Redressal Cell at any of the below- Malad link road, Malad (west), Mumbai – 400064
mentioned helplines: • Email us at
• Lodge your complaint online at head.customerservice@bharti-axalife.com
www.bhartiaxa.com You are requested to inform us about your concern (if
• Call us at our toll free no. 1800 102 4444 any) within 8 weeks of receipt of resolution as stated
• Email us at complaints.unit@bharti-axalife.com above, failing which it will be construed that the
complaint is satisfactorily resolved.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |4

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

If you are not satisfied with the response or do not [A Leaflet containing the simplified version of the
receive a response from us within 14 days, you may provisions of Section 45 is enclosed in appendix – III
approach the Grievance Cell of the Insurance for reference]
Regulatory and Development Authority (IRDA of
India) of India on the following contact details:
Section 13 of the Insurance Ombudsman Rules,
IRDA of India Grievance Call Centre (IGCC) TOLL 2017: Duties and Powers of Insurance Ombudsman
FREE NO:155255 or 18004254732 1) The Ombudsman shall receive and consider complaints
Email ID: complaints@irda.gov.in or disputes relating to—
You can also register your complaint online at a) Delay in settlement of claims, beyond the time specified
http://www.igms.irda.gov.in/ in the regulations, framed under the Insurance
Address for communication for complaints by paper: Regulatory and Development Authority of India Act,
Consumer Affairs Department 1999;
Insurance Regulatory and Development Authority of b) Any partial or total repudiation of claims by the
India Company;
Sy no.115/1, Financial District, c) Disputes over premium paid or payable in terms of
Nanakramguda, Gachibowli, Hyderabad – 500032 insurance policy;
d) Misrepresentation of policy terms and conditions at any
Step 3: If you are not satisfied with the time in the policy document or policy contract;
resolution provided by the company e) Legal construction of insurance policies in so far as the
In case you are not satisfied with the decision/ dispute relates to claim;
resolution of the Company, you may approach the f) Policy servicing related grievances against insurers and
Insurance Ombudsman. The complete list of Insurance their agents and intermediaries;
Ombusdsman is appended below in Appendix I or
please visit the website mentioned below for latest list g) issuance of life insurance policy, general insurance
of Insurance Ombudman: policy including health insurance policy which is not in
conformity with the proposal form submitted by the
• www.bhartiaxa.com
proposer;
• www.irdaindia.org/ombudsmenlist
h) Non-issuance of insurance policy after receipt of
For informative purpose and for your ready reference,
premium in life insurance; and
the relevant clause/s of the Insurance Act, 1938 as
amended from time to time are reproduced below: i) any other matter resulting from the violation of
provisions of the Insurance Act, 1938, as amended from
time to time, or the regulations, circulars, guidelines or
Section 41 of the Insurance Act, 1938, as amended
instructions issued by the IRDAI from time to time or
from time to time:
the terms and conditions of the policy contract, in so far
(1) “No person shall allow or offer to allow, either directly as they relate to issues mentioned at clauses (a) to (f).
or indirectly, as an inducement to any person to take out 2) The Ombudsman shall act as counselor and mediator
or renew or continue an insurance in respect of any kind relating to matters specified in sub-rule (1) provided
of risk relating to lives or property in India, any rebate there is written consent of the parties to the dispute.
of the whole or part of the commission payable or any
rebate of the premium shown on the Policy, nor shall 3) The Ombudsman shall be precluded from handling any
matter if he is an interested party or having conflict of
any person taking out or renewing or continuing a
interest.
Policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectus or 4) The Central Government or as the case may be, the
tables of the insurer: IRDAI may, at any time refer any complaint or dispute
relating to insurance matters specified in sub-rule (1), to
(2) Any person making default in complying with the the Insurance Ombudsman and such complaint or
provisions of this section shall be liable for a penalty dispute shall be entertained by the Insurance
which may extend to ten lakh rupees.” Ombudsman and be dealt with as if it is a complaint
made under Clause provided herein below.
Section 45 of Insurance Act, 1938 as amended from
time to time:
Fraud, Misrepresentation and forfeiture would be dealt Section 14 of the Insurance Ombudsman Rules,
with in accordance with provisions of Sec 45 of the 2017: Manner in which complaint to be made
Insurance Act 1938 as amended from time to time. 1. Any person who has a grievance against the Company,

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |5

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

may himself or through his legal heirs, nominee or iii. the complainant is not satisfied with the reply given
assignee, make a complaint in writing to the Insurance to him by the Company;
Ombudsman within whose territorial jurisdiction the b. The complaint is made within one year—
branch or office of the Company complained against or
the residential address or place of residence of the i. after the order of the Company rejecting the
complainant is located. representation is received; or
2. The complaint shall be in writing, duly signed by the ii. after receipt of decision of the Company which is not
complainant or through his legal heirs, nominee or to the satisfaction of the complainant;
assignee and shall state clearly the name and address of iii. after expiry of a period of one month from the date
the complainant, the name of the branch or office of the of sending the written representation to the Company if
Company against whom the complaint is made, the facts the Company fails to furnish reply to the complainant.
giving rise to the complaint, supported by documents, 4. The Ombudsman shall be empowered to condone the
the nature and extent of the loss caused to the delay in such cases as he may consider necessary, after
complainant and the relief sought from the Insurance calling for objections of the Company against the
Ombudsman. proposed condonation and after recording reasons for
3. No complaint to the Insurance Ombudsman shall lie condoning the delay and in case the delay is condoned,
unless— the date of condonation of delay shall be deemed to be
a. the complainant makes a written representation to the the date of filing of the complaint, for further
Company named in the complaint and— proceedings under these rules.
5. No complaint before the Insurance Ombudsman shall be
i. either the Company had rejected the complaint; or maintainable on the same subject matter on which
ii. the complainant had not received any reply within a proceedings are pending before or disposed of by any
period of one month after the Company received his court or consumer forum or arbitrator.
representation; or

List of Ombudsman
(For the updated list You may refer to IRDA of India website)

Address & Contact Details of Ombudsmen Centres

Governing Body of Insurance Council (Monitoring Body
for Offices of Insurance Ombudsman)
3rd Floor, Jeevan Seva Annexe, S V Road, Santacruz (West), Mumbai – 400054.
Tel no: 022-26106671/6889/980. Email id: inscoun@ecoi.co.in website: www.gbic.co.in
==============================================================================
If you have a grievance, approach the grievance cell of Insurance Company first. If
complaint is not resolved/ not satisfied/not responded for 30 days then You can
approach The Office of the Insurance Ombudsman (Bimalokpal)

Please visit our website for details to lodge complaint with Ombudsman.

Office of the Ombudsman Contact Details Areas of Jurisdiction

AHMEDABAD Tel.:- 079 - 25501201/02/05/06 Gujarat,

Office of the Insurance Ombudsman, Email: bimalokpal.ahmedabad@ecoi.co.in Dadra & Nagar Haveli,
Jeevan Prakash Building, 6th floor, Daman and Diu
Tilak Marg, Relief Road,
Ahmedabad – 380 001

BENGALURU Smt Neerja Shah Tel.: 080 - 26652048 / 26652049 Karnataka

Office of the Insurance Ombudsman, Email: bimalokpal.bengaluru@ecoi.co.in
Jeevan Soudha Building,PID No. 57-27-N-
19
Ground Floor, 19/19, 24th Main Road,

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |6

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

JP Nagar, Ist Phase,

BENGALURU – 560 078.

BHOPAL Smt Guru Saran Shrivastava Tel.: 0755 - 2769201 / 2769202 Madhya Pradesh
Office of the Insurance Ombudsman, Fax: 0755 - 2769203 Chattisgarh
Janak Vihar Complex, 2nd Floor, Email: bimalokpal.bhopal@ecoi.co.in
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
BHOPAL- 462 003.

BHUBANESHWAR Tel.: 0674 - 2596461 /2596455 Orissa

Office of the Insurance Ombudsman, Fax: 0674 - 2596429
62, Forest Park, Email:bimalokpal.bhubaneswar@ecoi.co.in
BHUBANESHWAR-751 009.

CHANDIGARH Dr. Dinesh Kumar Tel.: 0172 - 2706196 / 2706468 Punjab,

Verma Fax: 0172 - 2708274 Haryana,
Office of the Insurance Ombudsman, Email: bimalokpal.chandigarh@ecoi.co.in Himachal Pradesh,
S.C.O. No. 101, 102 & 103, 2nd Floor, Jammu & Kashmir,
Batra Building, Sector 17 – D, Chandigarh.
CHANDIGARH-160 017.

CHENNAI Shri M Vasantha Krishna Tel.: 044 - 24333668 / 24335284 Tamil Nadu,
Office of the Insurance Ombudsman, Fax: 044 - 24333664 Pondicherry Town and
Fatima Akhtar Court, 4th Floor, 453, Email: bimalokpal.chennai@ecoi.co.in Karaikal (which are part of
Anna Salai, Teynampet, Pondicherry).
CHENNAI-600 018.

DELHI - Tel.: 011 - 23239633 / 23237532 Delhi

Office of the Insurance Ombudsman, Fax: 011 - 23230858
2/2 A, Universal Insurance Bldg.,Asaf Ali Email: bimalokpal.delhi@ecoi.co.in
Road,
NEW DELHI-110 002.

GUWAHATI Shri Kiriti .B .Saha Tel.: 0361 - 2132204 / 2132205 Assam,

Office of the Insurance Ombudsman, Fax: 0361 - 2732937 Meghalaya,
Jeevan Nivesh, 5th Floor, Email: bimalokpal.guwahati@ecoi.co.in Manipur,
Nr. Panbazar over bridge, S.S. Road, Mizoram,
GUWAHATI-781 001(ASSAM) Arunachal Pradesh,
Nagaland and Tripura.

HYDERABAD. Shri I.Suresh Babu Tel.: 040 - 65504123 / 23312122 Andhra Pradesh,
Office of the Insurance Ombudsman, Fax: 040 - 23376599 Telangana,
6-2-46, 1st floor, "Moin Court", Email: bimalokpal.hyderabad@ecoi.co.in Yanam and
Lane Opp. Saleem Function Palace, part of Territory of Pondicherry.
A. C. Guards, Lakdi-Ka-Pool,
HYDERABAD-500 004.

JAIPUR Smt Sandhya Baliga Tel.: 0141 - 2740363 Rajasthan

Office of the Insurance Ombudsman, Email: bimalokpal.jaipur@ecoi.co.in
Jeevan Nidhi II, Ground Floor,
Bhawani Singh Marg,
JAIPUR – 302005.

ERNAKULAM Tel.: 0484 - 2358759 / 2359338 Kerala,

Office of the Insurance Ombudsman, Fax: 0484 - 2359336 Lakshadweep,
2nd Floor, Pulinat Bldg., Email: bimalokpal.ernakulam@ecoi.co.in Mahe-a part of Pondicherry
Opp. Cochin Shipyard, M. G. Road,
ERNAKULAM-682 015.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |7

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

KOLKATA Tel.: 033 - 22124339 / 22124340 West Bengal,

Office of the Insurance Ombudsman, Fax : 033 - 22124341 Sikkim,
Hindustan Building. Annexe, 4th Floor, Email: bimalokpal.kolkata@ecoi.co.in Andaman & Nicobar Islands.
4, C.R.Avenue,
KOLKATA - 700072

LUCKNOW Tel.: 0522 - 2231330 / 2231331 Districts of Uttar Pradesh:

Office of the Insurance Ombudsman, Fax: 0522 - 2231310 Laitpur, Jhansi, Mahoba,
6th Floor, Jeevan Bhawan, Phase-II, Email: bimalokpal.lucknow@ecoi.co.in Hamirpur, Banda, Chitrakoot,
Nawal Kishore Road, Hazratganj, Allahabad, Mirzapur, Sonbhabdra,
LUCKNOW-226 001. Fatehpur, Pratapgarh,
Jaunpur,Varanasi, Gazipur, Jalaun,
Kanpur, Lucknow, Unnao, Sitapur,
Lakhimpur, Bahraich, Barabanki,
Raebareli, Sravasti, Gonda,
Faizabad, Amethi, Kaushambi,
Balrampur, Basti, Ambedkarnagar,
Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria,
Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.

MUMBAI Shri Milind A. Kharat Tel.: 022 - 26106552 / 26106960 Goa,

Office of the Insurance Ombudsman, Fax: 022 - 26106052 Mumbai Metropolitan Region
3rd Floor, Jeevan Seva Annexe,S.V. Road, Email: bimalokpal.mumbai@ecoi.co.in excluding Navi Mumbai & Thane.
Santacruz(W),
MUMBAI-400 054.

NOIDA Tel.: 0120-2514250 / 2514252 / 2514253 State of Uttaranchal and the

Office of the Insurance Ombudsman, Email : bimalokpal.noida@ecoi.co.in following Districts of Uttar
Bhagwan Sahai Palace, 4th Floor, Pradesh:
Main Road, Naya Bans, Sector-15, Distt. Agra, Aligarh, Bagpat, Bareilly,
Gautam Buddh Nagar Bijnor, Budaun, Bulandshehar,
U.P – 201301. Etah, Kanooj, Mainpuri, Mathura,
Meerut, Moradabad,
Muzaffarnagar, Oraiyya, Pilibhit,
Etawah, Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad,
Hardoi, Shahjahanpur, Hapur,
Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.

PUNE Tel.: 020-41312555 Maharashtra,

Office of the Insurance Ombudsman, Email: bimalokpal.pune@ecoi.co.in Area of Navi Mumbai and Thane
Jeevan Darshan Bldg., 3rd Floor, C. T.S No.s excluding Mumbai Metropolitan
195 to198, N.C. Kelkar Road, Narayan Peth, Region.
PUNE – 411030.

PATNA Tel.: 0612-2680952 Bihar, Jharkhand.

Office of the Insurance Ombudsman, Email id: bimalokpal.patna@ecoi.co.in.
1st Floor, Kalpana Arcade Building,
Bazar Samiti Road, Bahadurpur,
PATNA – 800006

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |8

 Policy Document – Bharti AXA Life Accidental Death Benefit Rider
A Non-Linked Non-Participating Individual Life Insurance Rider

BEWARE OF SPURIOUS/FRAUD PHONE CALLS!

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums.
Public receiving such phone calls are requested to lodge a police complaint.

UIN: 130B008V02 Modified Version Date- 1st January 2020 P age |9

 5106378376
Bharti AXA Life Common Proposal Form
In case of a unit linked product, the investment risk in the investment portfolio under the Insurance policy will be borne by the Policyholder
Proposal Form For Life Insurance
Paste Your
Life / Financial Advisor / Specified Person of Corporate Agent / Employee of Broker Code/Web Aggregator Code/Online : 297470
Recent
Name: AUTHENTIC INS BRK HYDERABAD Source Code Passport Size
Photograph
MOA/MOM/Sales Manager/Corporate Agent/Broker Code: NA
Here
Bank Name AUTHENTIC INS BROKER INDIA LTD Bank Branch Code _ NA Bank Source Code Applicable
only for
Bank Partners
Bank Employee Referral Code Bank Customer id LMS Code

Customer ID: NA Policy No. 503-5727899 cKYC NA

POLICY CATEGORISATION ✔ General HUF Keyman Employer- Employee MWP Act Partnership
This form is to be filled in BLOCK LETTERS and a space should be left between each word. Please answer all questions. If any of the questions are not applicable, please write N.A and please tick the
[box] where appropriate/applicable. Any correction/alteration in this form needs to be signed by the Proposer and Joint Life (If opted) and all documents submitted with this Proposal must be
self-attested by the Proposer and Joint Life (If opted). Insurance is a contract of utmost good faith and the Life to be Insured and Proposer (If different from Life to be Insured) and Joint Life (If opted)
is required to disclose all material facts to the insurer. Please attach an extra sheet, where any additional information needs to be given. You are requested to pay cash premium only at the branch of
the Company or at authorized collection points and not to the Life Advisor or Employee. The Company will not be responsible for any loss in this regard

Parameters Life to be Insured Proposer (if different from Life to be Insured) and Joint Life (If opted)

1. Name :
Life to be Insured First Name: DHANARAJ First Name:
Mr. ✔ Mrs. Ms. Mx.
Middle Name: Middle Name:
Proposer and Joint Life (If opted)
Mr. Mrs. Ms. M/s. Last Name: KUMARESH Last Name:
Mx
2. Place and Date of Birth Place: BANGALORE Date: 12/02/1974 Place: Date :
3.Father Name DHANARAJ

4.Spouse Name GAYATHRI

5.Mother Name KUMARI

6. Correspondence Address C/O DHANARAJ M

[if different for Life to be Insured NO 41, 1ST BLOCK, NEAR AYYAPPA TEMPLE
and Proposer and Joint Life
Landmark SIDDARTHANAGAR, JALAHALLI WEST Landmark
(If opted)]
Village: Taluka: BENGALURU Village: Taluka:
City: BANGALORE NORTH Pin Code 560015 State KARNATAKA City: Pin Code State
7. Permanent Address C/O DHANARAJ M,NO 41, 1ST BLOCK, NEAR AYYAPPA TEMPLE
SIDDARTHANAGAR, JALAHALLI WEST
City: BANGALORE NORTH Pin Code 560015 State KARNATAKA City: Pin Code State
8. Gender & Nationality Male ✔ Female Male Female
Indian ✔ NRI Other Indian NRI Other
Transgender Transgender
9. Marital Status
Single Married ✔ Divorced Widowed Single Married Divorced Widowed

Mobile: 0 9035607632 Mobile: 0 9353226569 Mobile: 0 Mobile: 0

Email ID: DKUMARESH12522@GMAIL.COM Email ID:
10. Contact Number
(with STD code) / Email ID I agree that all communications will be on the email id and contact number mentioned above. ✔
I agree to receive my policy bond electronically at my registered email id and agree to receive communications
i.e. SMS, Email, etc.
Please tick if you wish to receive communications via WhatsApp
11. Age Proof (Self Attested) Birth Certificate Passport PAN Card ✔ Driving License Birth Certificate Passport PAN Card Driving License
School/College Other School/College Other
Certificate (Specify) Certificate (Specify)
12. Education Professional Post Graduate Graduate Diploma Professional Post Graduate Graduate Diploma
12th Pass ✔ 10th Pass Below10th Illiterate 12th Pass 10th Pass Below10th Illiterate
Salaried Professional Business ✔ Student Retired Salaried Professional Business Student Retired
13. Occupation Details
Housewife Self-Emp Agriculture Others Housewife Self-Emp Agriculture Others
 Section B

1. Name of Employer / KUMARESH ENTERPRISES

Business
2. Job Description/ OTHERS
Designation and period of 12
working
3. Annual Income (Total) 780,000

4. Source of Income BUSINESS

5. PAN CLOPK1101M
(Permanent Account
Number)## **Form 60 is required if PAN is not available **Form 60 is required if PAN is not available
6. Is proposer and Joint NA
Life (If opted) registered No Yes If Yes, provide GST No.
under GST Act^ (Please attach copy of GSTN certificate)
7. Relationship of Propose Mother Spouse
to the Insured
Father Employer Other ✔ (Specify): SELF

Passport Voter's ID Driving License Passport Voter's ID Driving License

8. Photo Identity Other Other
(Specify): PAN (Specify):
Passport Voter's ID Driving License Passport Voter's ID Driving License
9. Proof of Residence Other Other
AADHAAR CARD
(Specify): (Specify):
10. Are you a politically Yes Yes
No ✔ No
exposed person (PEP)?
("PEPs are Individuals who are or have been entrusted with prominent public functions domestically or by a foreign country or by an intemational organization, for
example, Heads of Stale or government, senior politicians, senior government, judicial or military officials, senior execulives of state-owrad corporations and important
political party officials OR Family members /close associates who are related or have business rolationships with PEP's) If your answers to PEP question changes
after the date hereabove mentioned, please kindly let us know within 30 days of such change.

11. Income proof submitted Latest Bank statement showing Salary Credits Salary Slip Latest Bank statement showing Salary Credits Salary Slip
(if applicable): ITR Form16 Other: NA ITR Form16 Other:
12. Are you a citizen of any Yes No ✔

country other than India? If yes, Please provide Name of the country(ies) NA

13. Are you a tax resident

Yes No ✔
of any other country (ies), NA
If yes, Please provide TIN with respect to each reportable jurisdiction:
Other than India?
*
If you are unsure of your tax residency, please check with your personal tax consultant.
**
If your tax residency changes after the date here above mentioned, please kindly let us know within 30 days of such change.
***
You are required to state the residency for tax purposes of the person or persons identified as the policyholder.
If the response to any of the above questions is yes, a detailed NRI questionnaire will have to be provided
##
PAN/Form 60 is mandatory. Form 60 is required if proposer and Joint Life (If opted) is exempted from PAN requirement.
^ GSTN certificate is required if the proposer and Joint Life (If opted) is registered under GSTN
2. Product Details

i. Product / Rider Name Sum Assured Premium Payment Policy Benefit Premium Payment Mode Renewal Premium Payment Method
Term Period
BHARTI AXA LIFE SECURE INCOME PLAN 155013.00 10 20 ECS** ✔ Credit Card**
Single Quarterly#
Annual ✔ Cheque/DD/Cash
BHARTI AXA LIFE ACCIDENTAL DEATH BENEFIT 50000.00 10 10 Monthly#
Semi-annual Other (Specify)
#For Monthly & Quarterly Mode Payment Only through ECS; **Please submit the specified form
Policy Backdated Yes No

Applicable for Bharti AXA Life Hospi Cash Rider, attachable to non-linked products only (Please tick anyone based on your choice of DHCB)
DHCB options
Bharti AXA Life Accidental Total & Permanent Disability Rider
Plan Options With Return of Premium Without Return of Premium
Applicable only for Bharti AXA Life Shining Stars
Maturity Payout Option Flexi Payout Option Annual Payout Option
Flexi Payout Option - 100% of the Sum Assured is paid at the time of Maturity. Flexibility to receive Maturity Benefit as a lumpsum amount at the end of any year during the Maturity Payout period.
Annual Payout Option - 22% of the Sum Assured is paid as five equal annual payouts at the end of every year during the Maturity Payout Period starting from the date of maturity.
Maturity Payout period is the period of 4 years from the date of maturity. The choice of the options can be taken either at policy inception or at least 90 days before the date of maturity.
Applicable only for Bharti AXA Life Super Endowment Plan
Death benefit Option Without Extended Life Cover Wlth Extended Life Cover
Extended Life Cover options (if opted for additional 100% of Sum assured will be payable throughout the policy term and Extended Life Cover term)
Policy Term 16 18 20
Extended Life Cover term 8 9 10
Select option
Applicable for Bharti AXA Life Income Protection Plan
Maturity Benefir Options: Option A Option B Death Bebefit Payout Period: 15 years 20 years
Maturity Benefir Options: Option A = 100% for all Policy Term options: Option B = 110%, 115% and 120% for 12 years, 15 years & 20 years respectively
 Applicable for Bharti AXA Life Premier Protect Plan
Plan Option Lumpsum Payout Monthly Income Payout Lumpsum + Monthly Income Payout
Applicable only for Bharti AXA Life Wealth Pro
Plan Option : Growth Legacy Investment Strategy Dynamic Fund Allocation Systematic Transfer Plan
Applicable for Bharti AXA Life Grow Wealth

Coverage Options Single Life Coverage Option Joint Life Coverage Option

Relationship of Joint life to Insured : Father Mother Spouse Child Grand Parent Other (Specify)
Single Life Coverage Option - Life Cover For Individual Only
Joint Life Coverage Option - Life Cover For two Individuals
Bharti AXA Life Guaranteed Income Pro
Plan Option: Endowment Option Short Term Income Long Term Income Deferred Income
Income Payout Frequency (applicable only for Income Options) : Annual Semi Annual Quarterly Monthly
Applicable for Bharti AXA Life Flexi Term Pro
Plan Option Without Return of Premium - Single Life Without Return of Premium - Joint Life With Return of Premium
Death Benefit Lumpsum Payout Monthly Income Payout Lumpsum + Monthly Income Payout
Payout Option
Increase sum assured
during the policy term* Yes No *Applicable in case of - To Age policy term for Regular Pay/Limited Pay till 60

Bharti AXA Life Unnati

1. Endowment Option
a) Base Variant b) Higher Death Benefit Variant c) Waiver of Premium Variant
2. Money Back Option
3. Immediate Income Option
4. Whole life Income Option
Applicable for Guaranteed Wealth Pro
Plan Option:
1. Endowment
2. Income
A) Short Term Income B)Long Term Income C)Life Long Income D)Early Income E) Long Term Early Income
Guaranteed Income payout frequency (applicable only for Income Options) :
A) Annual B)Semi Annual C)Quarterly D) Monthly
ii. Premium Details: Base Plan (Rs.) 26749.04 Rider Premium (Rs.) 40.00 Non Standard age Proof charges, if applicable (Rs.) 0.00

Total amount paid (Rs.) 28000.00 Mode of payment: Cash Cheque DD Other (specify) Online - Link
iii. Cheque / DD details: Date Cheque/DD No. Issuing Bank Name: Payable at Branch:
A/c No. (Cheque / DD should be made payable to "Bharti AXA Life Insurance Company Limited")
iv. Premium Payment through cheque by a person other than the proposer and Joint Life (If opted) Yes No ✔ Relation with the Proposer Joint Life (If opted) SELF
v. Details required for NEFT Transfer: Bank Account Holder’s Name: _______________________________________________
KUMARESH D Bank Account Number: __________________________
3195101000019
Bank Name: ________________________________________________________________________________
CANARA BANK Bank Branch Name: _____________________________________
JALAHALLI BANGALORE
Type of account: __________________________
SAVINGS IFSC Code: ________________________________
CNRB0003195
Please attach an original personalized cancelled cheque and in case the cheque does not bear the pre printed name of the account holder /bank account number please attach latest self attested 3 month Bank statement showing accountholders' name,
address and contact number

Growth Opportunities Plus ________% Grow Money Plus ________% Build India ________%
vi. Fund Allocation (Choosing a fund
SFIN:ULIF01614/12/2009EGRWTHOPPL130 SFIN: ULIF01214/12/2009EGROMONYPL130 SFIN:ULIF01909/02/2010EBUILDINDA130
is mandatory with min. 5%)
(applicable only for Unit Linked Policies) Save’n’grow Money ________% Steady Money ________% TOTAL = 100%
SFIN: ULIF00121/08/2006BSAVENGROW130 SFIN: ULIF00321/08/2006DSTDYMONEY130 Safe Money ________%
Stability Plus Money________% SFIN: ULIF01007/07/2009LSAFEMONEY130
SFIN:ULIF02322/02/17STAPLUMONF130
3. Nominee
(Not to be filled if Life to be Insured and Proposer and Joint Life (If opted) are different)
i. Name: ______________________________________
GAYATHRI Date of Birth: D D05/04/1978
/ M M/ Y Y Y Y Gender ________________ Relationship to Life to be Insured: WIFE % share 100.0

i. Name: ______________________________________ Date of Birth: D D / M M/ Y Y Y Y Gender ________________ Relationship to Life to be Insured: % share
iii. Name of Appointee (if Nominee is Minor):______________________________
NA Relationship of Appointee to Nominee:______________________________
NA
Address___________________________________________________ Signature of Appointee:_________________ Gender of Appointee _________________

4. Insurance History
Life Insured Proposer (to be filled if proposer opts for Premium Waiver Rider) and Joint Life (If opted)
Policy/ Company Date of Sum In Force / Policy/ Company Date of Sum In Force /
Proposal No. Name Issue/ Assured Lapsed Proposal No. Name Issue/ Assured Lapsed
i. Details of existing / Proposal Proposal
i. Details of existing /
Proposed Insurance
NO NO NO NO NO Proposed Insurance
(with Bharti AXA or any
(with Bharti AXA or any other
other Insurance company)
Insurance company)

ii. Details of Family Income and family Insurance

a. For unemployed: if single, provide family insurance. If married, then Spouse insurance. b. To be filled only if Life to be Insured is Minor
Relationship to Life to be Insured Spouse Father Mother Relationship to Life to be Insured Father Mother Brother(s) Sister(s)
Total Sum Assured
Total Sum Assured Are all the siblings Insured Yes No
Income If No, give detail:
 5. Lifestyle & Personal Details
(If "'yes" to any question below please fill relevant questionnaire) Proposer (to be filled If proposer opts for PremiumWalver Rider) and Joint Life (If opted)
Life Insured Proposer and Joint Life (If opted )
1. Do you plan to live or travel outside India for more than 30 days? If ‘yes’ please give details: Yes No ✔ Yes No
2. Have you in the past used or do you use any habit forming durgs or narcotics or received any drug abstinence treatment? Yes No ✔ Yes No
If ‘yes’ please give details:
3. Do you consume alcohol? If YES specify per week consumption: Beer (Glasses) ______ Hard Liquor (mis)______Wine(m/s)____ Yes No ✔ Yes No
4. Do you smoke or consume tobacco in any form e.g (paan, tobacco, gutka), or have done so in the past twelve months?
For Life Insured: If "YES" , Specify per day consumption: Yes No ✔ Yes No
Cigarettes sticks_____________ Cigar sticks_____________ Bidi sticks____________ Gutkha Pouch_____________ Paan___________
For Proposer and Joint Life (If opted): If *YES", Specify per day consumption:
Cigarettes sticks_____________ Cigar Sticks___________ Bidi sticks____________ Gutkha Pouch_____________ Paan___________
5.(a) For Life Insured: Height_________/_________
5 7 in (cm/ feet and inches) Weight (in Kgs)__________
69
(b) Has there been any variation in weight during the past twelve months? If Yes, please mention gain/ loss (in kg)___________ Yes No ✔ Yes No
Reasons ___________________________________________________________________________________________________________________
(a) For Proposer and Joint Life (If opted): Height________ / ________ in (cm/ feet and inches) Weight (in Kgs)______:
(b) Has there been any variation in weight during the past twelve months? If Yes, please mention gain/ loss (in kg)___________
Reasons _____________________________________________________________________
6. Family Physician's Name and Contact No.:_________________________________________________________________________________
7. Are you an Employee of Bharti group, AXA India group/ individual agents of Bharti AXA Life/ employee of corporate agents/brokers/
distribution partners of Bharti AXA Life or the spouse of any of the above? Yes No ✔ Yes No
Corporate Email Id______________________________________ & Employee Id __________________________________
8. Are you an employee of a Corporate partnered with Bharti AXA Life ? Yes No ✔ Yes No
Corporate Email Id_________________________________________ & Employee Id _________________________________
9. Are you an existing customer of Bharti AXA Life ? COI No/ Policy No. ______________________________ (If Answer is "Yes") Yes No ✔ Yes No

6. Family History
Life Insured Proposer (to be filled if proposer opts for Premium Waiver Rider) and Joint Life (If opted)
Family Member Living Deceased Living Deceased
Age Health Status Age at Death Cause of Death (for cancer include site) Age Health Status Age at Death Cause of Death (for cancer include site)

7. Health Records of Life To Be Insured (Proposer Answer To Be Filled If Proposer Opts For Premium Waiver Rider) And Joint Life (If Opted)

If the answer to any of the questions below is “YES”, please give full details in the box below or complete the relevant questionnaire wherever applicable.

Proposer and Joint

Life Insured Life (If opted)
1. Has any application for Ilfe, critical Iliness or health Insurance on your life ever been declined, deferred, or accepted with higher Yes No ✔ Yes No
than standard premiums or an exclusion applied on health grounds?
2. Have you ever been incapable to work for more than 7 days or presently incapable to work? Yes No ✔ Yes No
3. Do you expose yourself to any danger in the pursuance of your occupation (e.g. Chemical factory mines) or intend to engage in
any dangerous pursuits such as skydiving, parachuting, hang gliding, motor sports, diving, climbing, caving, or any other dangerous
sports or are involved in aviation as a pilot, co-pilot, pilot instructor or student pilot? Yes No ✔ Yes No

4. Have you ever had or received medical advice or treatment for any of the following?
a. Disorders of blood pressure, chest pain, any heart disease, stroke, epilepsy, cancer (including skin cancers) or any tumor, lump, Yes No ✔ Yes No
cyst, polyps, or growth of any kind
b. Asthma or any respiratory disease, kidney or urinary tract disease, mental or any nervous disease, any liver disease, any blood Yes No ✔ Yes No
disorders (including anemia), any digestive and bowel disorder, raised blood sugars, any metabolic or endocrine disorder
(including thyroid disorders), disorders of ears or eyes, the problem of stones in any organ in the body Yes No ✔ Yes No
c. Any disorder of the bones, spine or muscle, auto immune diseases
d. HIV infection, AIDS or AIDS related complications or Sexually Transmitted disease? Yes No ✔ Yes No
e. congenital/birth defects Yes No ✔ Yes No
5. Are you currently receiving any medical treatment or do you intend seeking or have been advised to seek medical treatment for
any health problems or are you waiting for the results of any tests/investigations? Yes No ✔ Yes No
6. Apart from the condition listed, have you ever seen a Doctor or other health professional, or been prescribed medication for any
other condition which has lasted for more than (apart from usual flue and colds) 5 days? Yes No ✔ Yes No
7. Has your biological mother, father, or any sister or brother been diagnosed prior to age 60 with any of the following? Cancer,
Yes No ✔ Yes No
Heart attack, Diabetes, Stroke, Huntington's disease or any other inherited conditions?
8. For female lives: a) Are you pregnant? If "YES", number of weeks______________
b) Have you, or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy Yes No ✔ Yes No
or confinement e.g. Caesarian section or miscarriage, high blood pressure, gestational diabetes, etc? (If "YES" state full details
8. a)________________ 8. a)________________
including dates)
8. b)________________
No 8. b)________________
FURTHER DETAILS REGARDING ANY OF THE ABOVE QUESTIONS ANSWERED “YES” IN SECTION 7
Life Insured Proposer and Joint Life (If opted)
Question number(s) / Medical Condition:
Date of diagnosis and treatment given:

Name of tablets or Medications:

Yes No. Yes No

Have you ever been hospitalized for this condition?
If yes, date of hospitalization: If yes, date of hospitalization:
Have you now fully recovered and stopped all

Details of declined / postponed proposals:

Name of the company
Reason

8. Annexure For Insurance Repository

1. Would you like to have an e-policy? Yes ✔ No

2. Do you have an eIA account number? If yes, please provide (Mandatory if Answer is “Yes”) Yes No ✔

3. If no, would you like to apply? (Mandatory if answer to Q1 is “yes” if answer to Q2 is “No”, please submit eIA request form) Yes ✔ No

4. Specify the Insurance Repository Name for elA creation. List of Insurance Repository:
NSDL Data Management Limited ✔ Central Depository Services Limited Karvy Insurance repository Limited CAMS Repository Services Limited

9. Declaration And Authorization

1. I/We hereby declare that the contents of this proposal for insurance have been fully explained to me including the significance of the proposed contract of
insurance.
2. 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.
3. I/We hereby understand and agree that the replies to the questions in the proposal, the details furnished in the enclosed questionnaires, the reports of any medical
examination, or laboratory tests, my proof of age and this declaration will be the basis of the contract of assurance between me and Bharti AXA Life Insurance
Company Ltd ( the "Company") and is subject to the Board approved underwriting policy of the Company and that the policy will come into force only after full
receipt of the premium chargeable.
4. In order to enable the Company to assess the risk under this proposal and any time thereafter, I/We hereby authorize the past and present employer(s)/ business
associates of mine, my medical practitioner/ hospital/ medical source/ any life and non-life Insurance Company/ organization or any other person to disclose to
the Company, the records of employment/ business or other details of mine as may be considered relevant for acceptance or otherwise of the proposal.
5. We agree and declare that the Company may without any reference to me (or to my beneficiary, as the case may be) disclose any information contained in the
proposal, the annexure, in the reports of any medical examination / laboratory tests or in the documents submitted by me / or procured by the Company / or as the
case may be / or submitted by my beneficiary, to any other insurer or to any reinsurer, to any claims investigator or any service provider engaged by the Company
for issuance, servicing and claim processing of the policies and with any Government and/or Regulatory Authority, CERSAl for ckyc number and eKYC services and
insurance repositories with respect to holding of the policy in an e Insurance Account.
6. I/we also agree that the PAN details and other information provided by me/us in the application form maybe used by the Bharti AXA Life Insurance Company
Limited to download/verify my/our KYC documents from the CERSAI’s CKYC portal for processing my/our application. I/We understand that for processing of the
application reliance shall be placed only on Officially Valid Documents. I hereby consent on receiving information from Central KYC registry through SMS/email
on the above registered mobile number/email address
7. I/We declare that the deposit towards the first premium and the renewal premium to be paid under the Policy are from legal sources of Income. I/We are not
involved in any criminal proceedings nor have any history of conviction in India or abroad.
8. I/We undertake to notify the Company forthwith, in writing, of any changes in my/our health, occupational and financial state and any proposal for insurance made
with any other company between the date of this proposal and the date of the acceptance of risk by the Company.
9. I/ We hereby understand and agree that Fraud or Misstatement would be dealt with in accordance with the provisions of Section 45 of Insurance Act, 1938 as
amended from time to time.
10. 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 proposal for
insurance.
Applicant Declaration for CKYC Registery: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I
undertake to inform you of any changes therein immediately. In case of any of the above information is found be false or untrue or misleading or
misstatement, I am aware that I may be held liable for it. I hereby consent to receiving information from Central CKYC regissty Through SMS / E-mail on the
above registered number / e-mail address.
Life to be Insured Proposer Sales Person Life / Financial Advisor / Witness
(If different from Life to be Insured) and Joint Life (If opted) Specified Person of Corporate Agent/ Broker
If electronically signed through OTP___mention If Signed electronically - mention
Signature / Thumb Impression The Document is electronically signed through OTP on The Document is electronically signed through login
____________________date &_________________time ID & Passwords of the Authorized sales Person
Date
Place
Name of the Witness: Address of the Witness

Declaration by Life Insured/Proposer Declaration of Person attesting the thumb print of applicant* (should not be affiliated to
Declaration by Personal filling the form Bharti AXA Life Insurance by virtue of being an employee, agent or third party distributor)
and Joint Life (If opted)
I hereby declare that I have fully I certify that the contents of the form have been I hereby declare that I have fully explained the above questions and contents of the proposal
explained the above questions to the
Proposer and Joint Life (If opted) and fully explained to me by the form to the proposer and Joint Life (If opted) in______________________________language, and
I have truthfully recorded the answers that the proposer has affixed the thumb impression above after fully understanding the
given by the Proposer Mr./Mrs.______________________________________ contents thereof
Name: Name: Name:
Designation
Occupation:
Signature Signature/Thumbprint: Signature
Address of the Declarant: Address of the Declarant: Address of the Declarant:
*
In case the Proposer is illiterate. his/her thumb impression should be attested by a person of standing whose identity can easily be established, but unconneted with the insurer and this
declaration should be made by him
Date
Place
SECTION 41 OF INSURANCE ACT 1938, as amended from time to time :
1. 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 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 prospectus or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakh rupees.

SECTION 45 OF INSURANCE ACT 1938, as amended from time to time :

Fraud and Misstatement would be dealt with in accordance with provisions of Section 45 of the Insurance Act 1938 as amended from time to time.
(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 can be called in question within 3 years from the date of commencement of the risk or date of revival or date of rider to the policy, whichever is later,
either or account of fraud or 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.
(3) However, no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement 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
(4) In case the policy is repudiated 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.
(For complete details of Section 45, please refer to Annexure I of Product Brochure)

Bharti AXA Life Insurance Company Limited

Registered address- Unit No. 1902, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road,
Behind MCA Ground, Bandra East, Mumbai- 400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor, Malad link road, Malad (west), Mumbai 400064. Maharashtra
Email: service@bhartiaxa.com, visit us at: www.bhartiaxa.com Regn No. 130
Renewal Autopay Details:
Bank Account Number 3195101000019
Account Holder Name Kumaresh d
IFSC Code CNRB0003195
Account Type SAVINGS
Bank Name CANARA BANK
Branch Name JALAHALLI BANGALORE
AutoPay Date 10
ECS Start Date 2022-06-22
Customer Declaration Form

5106378376
Proposal form ID/Application number___________________________

DHANARAJ KUMARESH
I/We ____________________________ request you to process the proposal
with the above mentioned application number submitted electronically to the Company.

Disclaimers:

I/We agree that the answers to the above questions are true and that this addendum forms a
part of the proposal/contract between me and Bharti AXA Life.

1. I/We declare and confirm that all the replies to the questions in the Suitability Assessment Form, e-
proposal, the details furnished in the enclosed questionnaires and the reports of any medical
examination are provided to the best of my/our knowledge. I/We declare that no material information
required by the Company to assess the risk on my life is withheld with me/us.
2. I/We declare that the content of the Suitability Assessment Form, Benefit Illustration, e-proposal
form and related documents have been fully explained to me/us and I/We have fully understood the
significance of the e-proposal form, related document and the proposed contract
3. I/We have submitted the e-proposal to buy this product on my/our accord after having read and
understood the terms and conditions of the said product on company’s website i.e.
www.bhartiaxa.com.
4. I/We have gone through the suitability process and the benefits as mentioned in the Benefit
illustration of the selected product. I/We have also verified the contents of the e-proposal form and
understand and agree that by submitting the One Time Password (OTP) received for the purpose of
insurance or by submitting this duly signed customer declaration form, I would be submitting this e-
proposal for Insurance and I/We will be bound by such statements/disclosures of material facts in the
same manner and to the same extent as if I/We had physically signed and submitted the Suitability
Form, Benefit Illustration, Written Proposal and related documents for insurance after having read and
understood the illustration of benefits.
5. I/We fully understand the nature of the questions including health related questions and the
importance of disclosing all material information to the company while answering such questions in
the e-proposal duly filled in the electronic mode by me/us or as per the information provided by me/us.
6. I/We declare that answers given by me/us to all questions in the e-proposal form including the
information given to the company as to the state of health and habits of the life/lives to be insured are
true and complete in every respect.
7. In order to enable the Company to assess the risk under this e-proposal and any time thereafter,
I/We hereby authorize the past and present employer(s)/ business associates of mine/ours, my/our
medical practitioner(s)/hospital/medical source/ any life and non-life Insurance Company/organization
to release to the Company the records of employment/ business or other details of mine as may be
considered relevant for acceptance or otherwise of the e-proposal.
8. I/ We declare that the deposit towards the first premium and the renewal premium to be paid under
the Policy are from legal sources of Income. I/We hereby declare and confirm that I/We am/are
making the premium payment towards this proposal through own bank account/credit card and I/We
agree to submit a third party declaration in case the premium payment is not made from own account.
9. In case of premium payment through cash, I understand and confirm that I will personally visit the
branch office of the Company for depositing the cash along with print of this e-proposal form.
10. I/We undertake to notify the Company forthwith, in writing, of any changes in my/our health,
occupational and financial state and any proposal for insurance made with any other company
between the date of this e-proposal and the date of the acceptance of risk by the Company.
11. I/ We hereby understand and agree that Fraud or Misrepresentation would be dealt with in
accordance with the provisions of Section 45 of Insurance Act, 1938 as amended from time to time.
12. I/We agree and confirm to the use of electronic medium, including email, as a mode for
communication from and to the Company.

Page 1 of 3
13. I/We hereby understand and agree that the replies to the questions in the e-proposal, the details
furnished in the enclosed questionnaires, the reports of any medical examination, or laboratory tests,
my proof of age and this declaration will be the basis of the contract of assurance between me and
Bharti AXA Life Insurance Company Ltd (the “Company'') and that if any statement made in the e-
proposal for insurance or to any medical examiner,or referee,or in any other document leading to the
issue of the policy is inaccurate or false, is on a material matter or facts which is material to disclose
or if any information provided or disclosure made by me/us at the time of e-proposal are in variance
with my/own financial position or health condition, physical or mental, as at the time of e-proposal or if
any of the documents submitted by me/us is found to be fake or forged then action will be taken
immediately to make the contract void. In case of fraud, misrepresentation and suppression of
material facts the policy contract shall be treated in accordance with the Section 45 of Insurance Act,
1938 as amended from time to time.
14. I/We agree and declare that the Company may without any reference to me (or to my beneficiary,
as the case may be) disclose any information contained in the proposal, the annexure, in the reports
of any medical examination/laboratory tests or in the documents submitted by me/us or procured by
the Company, to any other insurer or to any reinsurer, to any claims investigator or any service
provider engaged by the Company for issuance, servicing and claim processing of the policies.
Likewise the Company may make available copies of the proposal form, annexures, reports of any
medical examination laboratory tests or any documents submitted by me/us(or as the case may be,
by my beneficiary) or procured by the Company, to any insurer, to any claims investigator or any
service provider engaged by the Company for servicing the policies. So also the Company may
without any reference to me/us (or, as the case may be, to my beneficiary) furnish to any court /
tribunal or other Authority any such information or proposal, annexure, reports or documents as may
be required of the Company or as may be considered necessary by the Company.
15. I/We will abide by Company’s directions on medicals through any medium. The Company or
Company’s representative/s may contact me/ us at the address provided in the e-proposal form in
connection with this e-proposal or resulting policy
16. I/We declare that should any statement(s) including health declaration be incomplete, false, wrong
or inaccurate or should there be any omission(s) or withholding of information on my/our part, the
company shall have the right to cancel the policy. The Policy will be cancelled immediately, subject to
fraud or misrepresentation being established by the company in accordance with Section 45 of the
Insurance Act, 1938 as amended from time to time.
17. I/We further state and confirm that whatever is stated, declared, confirmed and agreed in this e-
proposal form and related document are done/effected on my/our own freewill and volition.
18. I/We consent/agree and hereby state that I have no objection in the Company conducting an
offline authentication of myself including offline KYC XML download for the purpose of availing Life
Insurance Policy from Bharti AXA Life Insurance Company and for servicing of said Policy. I/We
further consent and state that I/We have no objection in authenticating myself with Aadhaar based
authentication system and UIDAI sharing of my Aadhaar details including name, father’s name, date
of birth, address , mobile number , email id, gender and image for Aadhaar based validation/e-Kyc
through biometric and/or One time Pin (OTP) authentication for the purpose of availing Life Insurance
Policy from Bharti AXA Life Insurance Company subject to Bharti AXA Life Insurance Company being
permitted to undertake such validation/e-KYC.
I/We understand that I /we may receive calls from Bharti AXA Life in relation to my application for
insurance or the resulting policy(ies). I/We give my consent to Bharti AXA Life to make such calls
when I am/we are registered under NDNC category.

OTP signing details / Signature of Life Signature of Proposed Policy Holder (If
Assured different)

OTP: 549349

Name Name DHANARAJ KUMARESH

Date Date 2022-06-15 11:54:22:5422

Page 2 of 3
Place Place Bangalore North

Page 3 of 3
 Steps to Financial Security
Product Suitability Questionnaire

CUSTOMER PROFILE

Name: DHANARAJ KUMARESH Gender: Male Female

Mobile Number: 9035607632 Email Address: DKUMARESH12522@GMAIL.COM

Occupation

Agriculturist Housewife Salaried Self Employed/Business Student Unemployed Others

Date of Birth: DD 12 MM 02 YYYY 1974

SUITABILITY PROFILE
Total Household Income Need

Upto 5 Lakhs 5 to 10 Lakhs Protection Savings

10 to 25 Lakhs 25 to 50 Lakhs Retirement Wealth Creation
above 50 Lakhs Income Childs Education & marriage
Investor Type
Aggressive - High Risk taking ability
Balanced - Moderate Risk taking ability
Conservative - Low Risk taking ability
Life Stage

Minor Young Unmarried Young Married Young Married with Children Married with Older Children
Nearing Retirement Retired

PRODUCT DETAILS
Product Name: BHARTI AXA LIFE SECURE INCOME PLAN Type of Product: MoneyBack

Premium: 27999.9 Premium Mode: Yearly Half Yearly Monthly Quaterly Single Premium

Policy Term: 20 Premium Payment Term: 10

PROPOSER DECLARATION
I understand and agree that the above recommendation is based on the information provided by me. I have been explained about the features of the product and I
understand it would be suitable for me based on my insurance and financial goals. I/we agree that by submiting the Product Suitability Questionnaire, I/We will be bound
by the same, in the same manner and to the same extent as if I/We had signed and submitted the Product Suitability Questionnaire / Form for insurance. I also authorize
Bharti AXA Life Insurance to call me with respect to this request despite being registered under Do Not Call Registry.

Proposer Name: DHANARAJ KUMARESH Proposer Signature:

SALES PERSON'S DECLARATION

I, confirm that I have explained the importance of this assessment to the prospect in the language of the prospect and have
recommended
suitable product(s) basis the information and need of the prospect.

Sales Person's Name: AUTHENTIC INS BRK HYDERABAD Sales Person's Code: 297470

Signature: Date: 2022-06-15

(Life Advisor/Specified Person of Corporate Agent/Authorised Sales person of Broker/Employee of Bharti AXA Life Insurance)

CALL US Bharti AXA Life Insurance Company Limited - IRDAI Registration No.: 130 | Registered Office: Unit No. 1904, 19th Floor, Parinee Crescenzo, ‘G’
1800-102-4444 Block, Bandra Kurla Complex, BKC Road, Near MCA Ground, Bandra East, Mumbai – 400051, Maharashtra. ADVT No: II-Nov-2019-1989 CIN:
SMS Us U66010MH2005PLC157108
SERVICE at 56677 Life Insurance Coverage is available. For further details on risk factors, policy exclusions, terms & conditions, please read the sales brochure carefully before
Write To Us concluding a sale.
At service@bhartiaxa.com or
send a letter to the nearest
Bharti AXA Life branch
Trade Logos and used in the document belongs to the Bharti Enterprises (Holdings) Private Ltd. and AXA SA respectively and are used byBharti
AXA Life under license.

BEWARE OF SPURIOUS/FRAUD PHONE CALLS! IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of
premiums. Public receiving such phone calls are requested to lodge a police complaint.

The documents are electronically signed through OTP sent to 9035607632 on 2022-06-15 11:54:22:5422
 Bharti AXA Life Secure Income Plan
A Non-Linked, Non-Participating Individual Life Insurance Savings Plan
ILLUSTRATION OF BENEFITS FOR BHARTI AXA LIFE SECURE INCOME PLAN
Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy offers guaranteed benefits thenthese will be clearly marked "guaranteed" in the
illustration table on this page. If your policy offers variable benefits then the illustrations on this page will show two different rates of assumed futureinvestment returns. These assumed rates of return are not guaranteed and they are not the upper or lower limits
of what you might get back, as the value of your policy is dependent on a number of factors including actual future investment performance.

Proposer Details Empty

Name of the Prospect/Policyholder : DHANARAJ KUMARESH Quote No.: 20651655128150622
Age as on last birthday : 48 Years Proposal No : Empty
Gender : Male Policy No.: Empty
Empty Empty
Life Insured Details Name of the Product: Bharti AXA Life Secure Income Plan
Empty Empty
Name of the Life Insured : DHANARAJ KUMARESH Tag Line: Non-Linked, Non-Participating Individual Life Insurance Savings
Age as on last birthday : 48 Years Plan
Gender : Male Unique Identification No: 130N056V05
GST Rate (incl. cess, if any): GST Rate applicable in 1st year is 4.500% and 2nd year
onwards is 2.250%. For Riders, 18% GST rate is applicable
Empty Empty
Policy Term (years): 20 Product Code : TNPE10
Premium Payment Term (years) : 10 Rider Code : ADB
Premium Mode: Yearly
Amount of Instalment Premium (Rs.): 27999.90
(incl. rider premium and GST)
This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option: NA Sum Assured Rs. 155013.00
Empty Empty Sum Assured on Death (at inception of the policy) Rs. 347737.00

Name of the Proposer:DHANARAJ KUMARESH Signature of the Proposer: ___________________________________

Registered address- Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor,Malad link road, Malad (west), Mumbai 400064. Maharashtra
IRDA Regn no.-130.Website: www.bharti-axalife.com
Page 1 of 4
The documents are electronically signed through OTP sent to 9035607632 on 2022-06-15 11:54:22:5
 Rider Details
Empty Rider 1
Rider Name Accidental Death Benefit Rider (UIN:130B008V02)
Rider Term (years) 10
Rider Premium Payment Term (years) 10
Rider Sum Assured (Rs.) 50000.00

Premium Summary
Empty Base Plan Rider 1 Total Instalment Premium
Instalment Premium without GST (Rs.) 26749.00 40.00 26789.00
GST in the First Year (Rs) 1203.70 7.20 1210.90
Instalment Premium with First Year GST (Rs.) 27952.70 47.20 27999.90
GST from 2nd Year onwards (Rs) 601.85 7.20 609.05
Instalment Premium with GST 2nd Year Onwards (Rs.) 27350.85 47.20 27398.05

*GST Rate applicable in 1st year is 4.500% and 2nd year onwards is 2.250%. For Riders, 18% GST rate is applicable

(Amounts in Rupees.)

Illustration summary over the duration of the policy

Guaranteed Benefits Non Guaranteed

Policy Year Annualized Premium Other Min Guaranteed Special Surrender

Survival Benefits Benefits(Cumulative Maturity Benefit Death Benefit
Surrender Value Value
Guaranteed Additions)4
1 26749 - - - 347737 - -

2 26749 - - - 347737 16049 32398

3 26749 - - - 347737 28086 50689

4 26749 - - - 347737 53498 70376

5 26749 - - - 347737 66873 91613

Name of the Proposer:DHANARAJ KUMARESH Signature of the Proposer:___________________________________

Registered address- Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor,Malad link road, Malad (west), Mumbai 400064. Maharashtra
IRDA Regn no.-130.Website: www.bharti-axalife.com
Page 2 of 4
The documents are electronically signed through OTP sent to 9035607632 on 2022-06-15 11:54:22:5
 (Amounts in Rupees.)

Illustration summary over the duration of the policy

Guaranteed Benefits Non Guaranteed

Policy Year Annualized Premium Other Min Guaranteed Special Surrender

Survival Benefits Benefits(Cumulative Maturity Benefit Death Benefit
Surrender Value Value
Guaranteed Additions)4
6 26749 - - - 347737 80247 114709

7 26749 - - - 347737 102984 139666

8 26749 - - - 347737 117696 166794

9 26749 - - - 347737 144445 196246

10 26749 - - - 347737 160494 228179

11 - 12401 15501 - 347737 161467 208957

12 - 12401 31003 - 347737 149066 215003

13 - 12401 46504 - 347737 163414 221358

14 - 12401 62005 - 347737 151013 228334

15 - 12401 77506 - 347737 165361 235929

16 - 12401 93008 - 347737 179709 244145

17 - 12401 108509 - 347737 194057 252981

18 - 12401 124010 - 347737 208405 262747

19 - 12401 139511 - 347737 222753 273442

20 - 12401 155013 155013 347737 250476 297624

Notes: Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any and Goods & Service Tax.

*Survival Benefits will be payable on monthly basis. Guaranteed income in policy year will be paid as Guaranteed Monthly Income to Policyholder. This amount will be equal to (Guaranteed Income in a Policy Year/12).

Name of the Proposer:DHANARAJ KUMARESH Signature of the Proposer:___________________________________

Registered address- Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor,Malad link road, Malad (west), Mumbai 400064. Maharashtra
IRDA Regn no.-130.Website: www.bharti-axalife.com
Page 3 of 4
The documents are electronically signed through OTP sent to 9035607632 on 2022-06-15 11:54:22:5
 Explanation & Information - Secure Income

1. This benefit illustration explains the benefits and features of the proposed policy and is not a contract of insurance.
2. The illustration is based on the standard risk class, taking in to consideration your own circumstances.
3. All benefits under this plan are guaranteed.
4. On maturity of the policy, the Sum Assured will be payable. Additionally, the Guaranteed Additions (as shown in Other Benefit column in the above illustration) will also be payable
5. The minimum guaranteed surrender value under the policy is 30% of all premiums paid till date if surrendered in 2nd year.The GSV is paid only if the policy aquires surrender value. The sum of all Guaranteed income paid till
the year of surrender will be deducted from this Guaranteed Surrender Value. The company may declare surrender value that is higher than the guaranteed Surrender Values (ie Special Surrender Value).
6. For more details on risk factors,terms and conditions please read sales brochure carefully before concluding a sale.
7. Tax benefits are as per the current tax legislations and are subject to change in tax laws. Neither the company nor its agent s can offer legal or tax advice.
8. Bharti AXA Life Insurance Company Ltd., Bharti AXA Life Secure Income Plan is the name of the Insurance Company, Product and does not in any way indicate the quality of the contract, its future prospects or returns.

Declaration by Advisor / Sales Person Declaration by Proposer

I, ___________________________________ (name), have explained the premiums, and benefits I, DHANARAJ KUMARESH, having received the information with respect to the above, have
under the product fully to the prospect / policyholder. understood the above statement before entering into the contract.

Place

Date : Signature of Agent/Intermediary/Official Date : Signature of Prospect / Policyholder

Registered address- Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra
Service Unit address- Bharti AXA Life Insurance Company Limited, Spectrum tower, 3rd Floor,Malad link road, Malad (west), Mumbai 400064. Maharashtra
IRDA Regn no.-130.Website: www.bharti-axalife.com
Page 4 of 4
The documents are electronically signed through OTP sent to 9035607632 on 2022-06-15 11:54:22:5