Canara HSBC Life Insurance Company Limited

PROPOSAL FORM
Proposal No: 7500224747
Unique Reference Number: CPF/V6.24/082025
“IN UNIT LINKED POLICIES, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE
POLICYHOLDER.”

For Office use only

Bank/Channel Name
Bank/Channel Code Client’s Branch/DSPCode
Please affix recent
Bank Account No.
Passport size
Customer Identification No. photograph of Proposer
Branch Representative Name and Sign across the
Branch Representative Code Insurance Sales Manager Code photograph

Customer Referred by
DO NOT STAPLE THE
Employee (Name)
PHOTOGRAPH
Referred by Employee (No.)
Employer Employee Hindu Undivided Family Individual Married Women's Property Act
Type of Insurance
Partnership Firm Salary Deduction Key man
Relationship with Bank Saving Bank Account Current Account Deposit Advance-Borrower Credit Card
YES NO Corporate Customer YES NO Point of Sale YES Point of Sales Person LI:
Staff
PAN No:

Important Guidelines:
1. Insurance is a contract of utmost good faith, requiring the Proposer and the Life to be Insured and the insurer to disclose all material facts. If
there is any doubt as to whether any fact is material, it should be disclosed. Failure to do so may invalidate the contract based on this form.
2. ALL INFORMATION IN THE PROPOSAL TO BE FILLED IN CAPITAL LETTERS USING BLACK BALL POINT PEN

Personal Details of Life to be Insured

1. Life to be Insured name Title ✔ Mr. Mrs. Ms. Other (specify)
First Name:- Madhur Middle Name:- Last Name:- Shrivastava
2. Is Life to be Insured our existing policyholder/applicant, kindly tick as Yes No If Yes, Policy/Application
applicable: No
3. Father’s Name Title ✔ Mr. Other (specify)

First Name:- Dinesh Middle Name:- Chandra Last Name:- Shrivastava

4. a) Date of Birth 20/10/1993
b) Country of Birth:- India c) City of Birth:- Gwalior d) Gender ✔ Male Female Transgender
e) Age Proof Unique Identification (UID)/ Aadhaar card
f) Marital Status Married
5. Is Life to be Insured
(Please fill NRI/PIO/Foreign National Questionnaire if applicable. In case of NRI/PIO/Foreign
National, all correspondence and communication shall be sent to the address provided for such
purpose in the NRI/PIO/Foreign National Questionnaire)
6. a) Country of current Residence India b) Citizenship :- India ( Please specify in case of
multiple citizenship)
c) Nationality India (Please specify in case of multiple
nationalities)
7. Communication Address ✔ Current Residential Address Permanent Residential Address Office Address
Pin Code is mandatory

8. Current Residential Address 109 adarsh colony, Gole ka mandir, Pali hospital, Near tiwari kirana store, Gwalior, Madhya
Pradesh-474003
9. Permanent Residential Address Flat No 4 Harihar Nagar Sagar, Tal Sagar Tal Gird Gwalior, Madhya Pradesh, Madhya Pradesh,
Gwalior, Madhya Pradesh-474009

10. a) Name of Organisation OTHER

/Business/Educational Institution
b) Nature of industry of the others
Employer/Organization
11. Office Address
Area/Taluka/Tehsil
City/District State
Country Pin Code
12. Education / Professional Qualification Graduate
13. Occupation Salaried
14)Exact nature of occupation/duties:- Teacher
(Specify if you are in money services /lottery / casino/gambling/horse jockey/NGO/Trust/Charity/Real Estate/Jewelry/Scrap Dealer/Diamond dealer)

15. Are there any risks associated with the Life to be Insured’s occupation? e.g. Working with Boiler, Explosives, Yes ✔ No
Chemicals, etc.
If Yes, Please fill up the appropriate questionnaire.
16. Annual Income (Rs.) 500000
17. Does Life to be Insured take part in hobbies that are risky in any way? e.g. Aviation, Diving, Mountaineering etc. Yes ✔ No
(If Yes, Please submit appropriate questionnaire.)
18. Is the Life to be Insured a Politically Exposed Person (PEP)? Yes ✔ No
(PEPs are individuals who are or have been associated with a political party/politician or holding any senior role in any
ministry/government/state owned enterprises/judicial body/military/police in India or abroad or those individuals who have any close family
members or associates in the said capacity)
If yes, please provide details
19. Contact Details : Mobile: ISD Code +91 7007357714 Alternate Mobile: ISD Code Number
Telephone/Mobile Number wherever available

Residence number Ph: STD Code Number Email

[email protected]
20. Do you have Ayushman Bharat Health Account (ABHA)?(If yes, please provide ABHA number) Yes No

Personal Health Details of Life to be Insured

1. Height___ft___ inches OR 177.8 cms Weight 87 Kgs
2 Has your weight altered by more than 5 Kgs. in the last 1 year for reasons other than exercise? Yes ✔ No
3. Please give the following details
Substance Consumed Yes/No If yes, consumed as Consumption Quantity For No. of years
Tobacco No
Alcohol No
Any Narcotics No
4. 1 Please provide medical details as asked in the following questions: (To be filled for Life to be Insured for Life Insurance Product, Major
Critical Illness & Heart Cover under Health Product)
 Medical Details of Life to be Insured (Applicable for Life Insurance Product)

Have you ever :

1. Been hospitalized for general checkup, observation, treatment or surgery? Yes ✔ No
2. Been prescribed treatment or medication for a current injury or ailment? Yes ✔ No
a. 3. Availed more than 5 days continuous leaves on medical grounds in the last 2 years or consulted a doctor/visited a Yes ✔ No
clinic in the past 6 months ?If yes, please provide details
4. Undergone/ Advised X-ray/CT-Scan/MRI/Ultrasound/ECG/Blood Test/any other tests/investigations Yes ✔ No
5. Undergone/Advised test/tested positive for Hepatitis, HIV/AIDS or any other sexually transmitted disease? Yes ✔ No
Have you ever suffered or are you suffering from any of the following?
1. Any ailments relating to heart like high/low blood pressure, chest pain, palpitation, rheumatic fever, heart attack, Yes ✔ No
shortness of breath, any other heart disorder or stroke etc.
2. Any ailments related to the brain & nervous system like epilepsy, stroke, depression, mental disorders etc. Yes ✔ No
3. Tumour, cancer, cyst, abnormal growth or any other malignancy Yes ✔ No
4. Disorders of eye, ear, nose or throat including defective sight, speech or hearing and discharge from ears Yes ✔ No
5. Asthma, bronchitis, tuberculosis, difficulty in breathing, persistent cough or any other lung disorder Yes ✔ No
b.
6. Ailment related to liver, gall bladder, stomach and digestive system like ulcers, stones, colitis, stomach pain, jaundice, Yes ✔ No
hepatitis B or C etc.
7. Any gland related disorder like diabetes/high blood sugar, sugar in urine, thyroid etc. Yes ✔ No
8. Any kidney system or urinary bladder disorder like stones, nephritis, prostate disorder, reproductive organs etc. Yes ✔ No
9. Musculoskeletal & joint disorder like gout, rheumatic arthritis, back disorder, Skin disorder etc. Yes ✔ No
10. Anaemia, disorders of blood (e.g. Haemophilia, Thalassemia) or any other illness not mentioned in (1 to 10) Yes ✔ No
11. Any physical disability/deformity, congenital disorder, paralysis or multiple sclerosis Yes ✔ No

Please provide details if answer of any of the above question is answered as “Yes”

Question Number Details

The Company reserves the right to ask for medical tests or/ seek further information based on above answers.
Please submit Previous Medical Reports (if any) and relevant questionnaire (s)

To be filled only if Linked Critical Illness Benefit Rider/Non-Linked Critical Illness Benefit Rider is Opted
1. Have you ever been diagnosed, investigated or treated for any of the following disease/ disorder:

Coronary artery disease, Chest Pain, Angioplasty, Bypass surgery, Valvular Heart Disease, Heart Attack, Stroke,
a. Transient Ischemic Attack (TIA), Rheumatic Disorder or any other cerebrovascular disease or abnormal Yes No
electrocardiogram (ECG), Treadmill Test or Echocardiogram?
Diseases of the nervous system or mental disorders (e.g. Creutzfeldt-Jakob disease, Encephalitis, Alzheimer's Disease,
b. Multiple Sclerosis, Parkinson's Disease , Apallic Syndrome, Muscular Dystrophy, poliomyelitis motor neuron disease, Yes No
Stroke, Epilepsy, bacterial meningitis, chronic depression or other mental or psychiatric disorder or suicidal thoughts)?
c. Diseases of the respiratory system (e.g. tuberculosis, Pulmonary Hypertension, End stage lung failure, Emphysema)? Yes No
Cancer or other malignant disease of any organ or blood/ lymphatic system, benign or malignant tumor, Bone Marrow
d. Yes No
Transplant, abnormal biopsy findings or any other unexplained growth?
Diseases of Renal system e.g. Chronic Kidney disease, Medullary Cystic Disease, Chronic Adrenocortical Insufficiency
e. Yes No
(Addison's disease), Systemic Lupus Erythematous?
f. AIDS, HIV or AIDS-related illness, Viral Hepatitis (B or C) or any other sexually transmitted disease? Yes No
Crohn’s, Ulcerative colitis, rectal bleeding, Chronic Recurring Pancreatitis, abnormal colonoscopy results, or any other
g. Yes No
disorder of the stomach, pancreas, colon, rectum, reproductive organs?
h. Loss of function of speech, vision and hearing as a result of disease, accident or congenital anomaly? Yes No

2. In the past 5 years:

a. Have you had an application for Critical Illness insurance declined, postponed or offered with a rating or exclusion? Yes No
Have you ever been treated or counseled or joined rehabilitation program for alcohol addiction or narcotic drugs
b. Yes No
use/abuse?
 To be filled if the Life to be Insured is a Female (For Females only)
1. Maiden Name of the Life to be Insured
2. Is the Life to be Insured pregnant at present? Yes No If yes, duration in weeks
3. Did the Life to be Insured ever suffer from or at present suffering from any gynecological related problems? Yes No
4. a. Husband’s Name
b. Annual Income
 Previous Insurance details of Life to be Insured
1. Life Insurance/Health Insurance already In Force/Lapsed/Revival/Applied for (including policies surrendered during the last 3 years)
(Please attach additional sheet if necessary with details as mentioned below)
Issuing Life Insurance Years of Sum Assured Annual Premium Riders if Acceptance Terms (Std./With Med
Company Issue (Rs.) (Rs.) any Extra/With Non Med Extra)
LIC 500000 NA Inforce -
Bajaj Allianz Life 10000000 NA Inforce -
2. Has a proposal on Life to be Insured’s life ever been withdrawn/postponed/declined/dropped or accepted with modified terms /extra premium
or has Life to be
Insured ever made any claim under a policy of Life/Health Insurance? Yes No
If yes, please give details-

Family Health Details of Life to be Insured

Please furnish details of family members of the Life to be Insured. Also in case of any family members suffering or having
suffered or died of heart disease, stroke, high blood pressure, diabetes, any form of eye disease, kidney disease, paralysis or
any hereditary/familial disorders, any communicable disease, or any disease not mentioned above, mention the same in the
following table. If the Life to be Insured is not aware, please leave it blank, the Company could ask for clarifications later. Please
attach additional sheet if necessary with details as mentioned below.

If Deceased If Alive
Family Member Age at Death Cause of Death Current Age Mention the name of disease/illness (if any)

Nominee Details
Note: Nominee/Beneficiary details to be provided, only where Life to be Insured is proposing on self
(In case of Multiple Nominees/ Beneficiaries, please fill up Multiple Nomination Form)
1. Nominee/ Beneficiary Name Title Mrs
First Name:- Bulbul Middle Name:- Last Name:- Shrivastav
2. a) Date of Birth 06/07/1995 b) Gender Female
Nominee Relationship with Life to be
3. Spouse
insured
Pin code is mandatory
4. Permanent Address of Nominee/Beneficiary
Area/Taluka/Tehsil 109 adarsh colony Gole ka mandir Pali hospital
City/District Gwalior State Madhya Pradesh
Country India Pin Code 474003
Current Address of Nominee/Beneficiary
Area/Taluka/Tehsil
City/District State
Country Pin Code
5. Contact details: +91 7007357714 Alternate Mobile with ISD Code
Telephone/Mobile Number wherever
Residence Ph Email-
available
6. Nominee Bank Details:
Bank Name
Account No. IFSC Code
1. Nominee/ Beneficiary Name Title Mr
First Name- Prem Middle Name- Last Name- Shrivastava
2. a) Date of Birth 21/08/2022 b) Gender Male
Nominee Relationship with Life to be
3. Son
insured
Pin code is mandatory
4. Address of Nominee/Beneficiary
 Area/Taluka/Tehsil 109 adarsh colony Gole ka mandir Pali hospital
City/District Gwalior State Madhya Pradesh
Country India Pin Code 474003
5. Contact details: Mobile with ISD Code Alternate Mobile with ISD Code
Telephone/Mobile Number wherever
Residence Ph Email
available
6. Nominee Bank Details:
Bank Name
Account No. IFSC Code

Appointee or Guardian Details (Other than the Life to be Insured), if the Nominee/Beneficiary is a minor (below 18 yrs)
1. Name of Appointee/ Guardian Title Mrs
First Name:- Bulbul Middle Name:- Last Name:- Shrivastav
2 a) Date of Birth 06/07/1995 b) Gender Female
3. Relationship with the Nominee/Beneficiary Mother
4. Address of Appointee/Guardian
Area/Taluka/Tehsil
City/District State
Country Pin Code
5. Contact details Mobile with ISD code Alternate Mobile ISD code
Telephone/Mobile Number wherever available Residence Ph Email
 Personal details of Proposer/Life to be Insured

Please fill as per instructions

(PLEASE FILL DETAILS OF PROPOSER FOR Q.1 TO Q.22 WHERE LIFE TO BE INSURED AND THE PROPOSER ARE DIFFERENT)
(PLEASE SKIP Q.1 TO Q.12 IF THE LIFE TO BE INSURED AND THE PROPOSER ARE SAME)

1. Proposer Name Title Mr. Mrs. Miss Ms. Other

First Name:- Middle Name:- Last Name:-
b) Gender:- Male
2. a) Date of Birth Female
Transgender
3. Father’s Name Title Mr. Others(Specify)
First Name:- Middle Name:- Last Name:-
4. Is Proposer Resident Indian NRI (Non Resident Indian) PIO (Person of Indian Origin) Foreign National
Company/ Partnership Firm/ HUF Other (specify)
(Please fill NRI/PIO/Foreign National Questionnaire if applicable. In case of NRI/PIO/Foreign National, all
correspondence and communication shall be sent to the address provided for such purpose in the
NRI/PIO/Foreign National Questionnaire)
5. Marital Status
6. a) Country of Residence b) Country of birth
c) City of Birth d) Citizenship
e) Nationality f) Annual Income (Rs.):-
7. a) Occupation Salaried Retired Housewife Student Business Owner/Self Employed
b) Exact nature of occupation/duties:-
(Specify if you are in money services/lottery/casino/gambling/horse jockey /NGO /Trust /Charity/Real Estate/Jewelry/Scrap Dealer/Diamond
dealer)
c) Organization/Employer d) Nature of industry of the
Name Employer/Organization
e) Office Address– Country f) Office Address -City
8. Are you a Politically Exposed Person (PEP)? Yes No
(PEPs are individuals who are or have been associated with a political party/politician or holding any senior role in any
ministry/government/state owned enterprises/judicial body/military/police in India or abroad or those individuals who have any close family
members or associates in the said capacity)
If yes, please provide details
9. Communication Address Current Residential Address Permanent Residential Address
Pin code is
mandatory
10. Current Residential Address
Area/Taluka/Tehsil
City/District State
Country Pin Code
11. Permanent Residential
Address
Area/Taluka/Tehsil
City/District State
Country Pin Code
12. Contact Details Mobile: ISD Number- Alternate Mobile:ISD Code Number-
Code
Telephone/Mobile Number Residence number Ph: STD Code Number- Email-
wherever available
13. Proof of Address Submitted Current Residential Address Permanent Residential Address
14. Address Proof PassPort Driving License Voters Identity Card NREGA Card Bank account or Post Office
savings bank account statement Others_______ (please specify)
15. Proof of Identity PassPort Voter Id Driving License NREGA Card Others_______ (please specify)
Passport/Voter ID/NREGA Card/ Driving License/Others Number
 Passport/Driving License/ Others Expiry Date
16. Proposer’s Relationship with ✔ Self Spouse Son Daughter Father Mother Other____
Life to be Insured
17. Mother’s Name Title ✔ Mrs. Ms. Other____
First Name:- Mamata Middle Name:- Last Name:- Devi
18. a) Tax Residency Country b) Tax Identification Number
(TIN number mandatory for other than India)
19. PAN No Eewps7718b (In case PAN is not submitted then FORM 60 is furnished)
20. Total Insurance Cover (Rs.)
21. a) e- Insurance Account Number (eIA)
b) Name of the Insurance Repository to which eIA is linked CAMS CDSL KARVY NSDL
c) If you do not have an eIA account, would you like to create one? ✔ Yes No
If yes, please name the preferred Insurance Repository CAMS CDSL KARVY ✔ NSDL
d). Do you need a physical copy of the policy document? ✔ Yes No
22. If the proposer is Company/ Partnership Firm/ HUF, following details to be provided:
a) Company/ Partnership Firm/ HUF Name:
b) Contact Person/ Proposer/ Nominee/ Beneficiary Name/ Authorized Signatory: Title Mr. Mrs.
Miss. Ms.
Other (specify)
(specify)
First Name Middle Name Last Name
23. Do you want to opt out of auto-vesting*? Yes No
(Auto-vesting implies that Life Assured will become Policyholder on the date of completion of 18 years of age)
*Available with Promise4Future only.

Product Details
Mode of Payment ✔ Monthly Quarterly Half-yearly Yearly Single Premium
Premium Deferment Period / Policy Coverage Amount Installment Premium
Plan/Coverage/Rider Name
Term Consolidation Period Term Proposed (Rs.) (Rs.)
Promise4Growth Plus - Care 15 25 300000 2500

Total Installment Premium (Rs.) 2500

For Traditional Plans:

I would like to opt for Settlement Option*1 Yes No

*2 Future Suraksha Income Suraksha{Income Period 10 years 15 years}
I would like to opt for Plan Option :
*2.5 Monthly Quarterly Half-yearly Yearly
I would like to opt for Income Frequency :
iAchieve {Optional cover Payor Premium Protection Cover} iAssure {Optional cover
I would like to opt for Plan Option*3:
Payor Premium Protection Cover} Flexi iAchieve Flexi iAssure Easy iAchieve
I would like to opt for Plan Option*4: Guaranteed Savings Option Guaranteed Cash Back Option
Short Term Income {Optional benefit Step up Income} Long Term Income {Income

*5
Pay-out Period
I would like to opt for Plan Option :
10 years 15 years 20 years
25 years 30 years } {Optional benefit Step up Income} Early Income
*5 7 times 11 times
I would like to opt for Sum Assured Multiple :
Endowment Option {Optional benefit Payor Premium Protection Cover
Accidental Death Benefit} Regular Income Option {Optional benefit Payor Premium
Protection Cover Accidental Death Benefit}
I would like to opt for Plan Option*6: Early Income Option { Optional benefit Accidental Death Benefit} { Income Period 19
29 39} Long Term Income with Return of Premium Option { Optional benefit
Accidental Death Benefit} {Income Period 15 20
30 40}
I would like to opt for Income Frequency*6 Monthly Yearly
# if opted, please fill second lifequestionnaire
I would like to opt for Plan Option*7 Income4Future Savings4Future
For Unit Linked Plans*:
Plan Name I would like to opt for
Secure Invest SecureInvest Choice SecureInvest Forever
promise 4 Growth Plus Promise4Wealth Plus ✔ Promise4Care Plus Promise4Life Plus
Wealth Edge Invest Plus Premium Plus Life Plus
Alpha Wealth Alpha Invest Plus Alpha Premium Plus Alpha Life Plus
Promise4Growth Promise4Wealth Promise4Care Promise4Life
0% 0% 0% 0% 0% 0% 0% 0% 0% 50 % 0% 0% 50 %
Nifty
Emerging India Midcap Multicap Nifty 500
Equity Growth Balanced Large Cap Alpha India
Leaders Multi-Cap Momentum Debt Liquid Momentum Multifactor
II Plus Plus Advantage 50 Manufacturing
Equity Equity Growth Fund Fund Quality 50 Index
Fund Fund Fund Fund Index Fund
Fund Fund Index Fund Index Fund Fund
Fund
The SFIN (Segregated Fund Index Number) for: Emerging Leaders Equity fund is ULIF02020/12/17EMLEDEQFND136, India Multi-Cap Equity
Fund is ULIF01816/08/16IMCAPEQFND136, Midcap Momentum Growth Index Fund is ULIF02218/03/24MIDMIEQFND136, Equity II Fund is
ULIF00607/01/10EQUTYIIFND136, Growth Plus Fund is ULIF00913/09/10GROWTPLFND136, Balanced Plus Fund is
ULIF01013/09/10BLNCDPLFND136, Large Cap Advantage Fund isULIF02109/06/20LARCPADFND136, Debt Fund is
ULIF00409/07/08INDEBTFUND136,Liquid Fund is ULIF00514/07/08LIQUIDFUND136, India Manufacturing Fund is
ULIF02305/11/24INMFGEQFND136, Multicap Momentum Quality Index Fund is ULIF02410/03/25MLMMQEQFND136 & Nifty Alpha 50 Index
Fund is ULIF02502/04/25NFALFEQFND136 & Nifty 500 Multifactor 50 Index Fund id ULIF02715/09/25/MLFACEQFND136.
Premium Funding Benefit Option Chosen* Death Only Death Or TPD
You can select your option(s) from the
following*
Auto Funds Rebalancing Milestone Withdrawal Option(MWO) @ Safety Switch Option
@
Systematic Withdrawal Option (SWO) , Choose Frequency of SWO Monthly Quarterly Half-yearly Yearly
Fund Value to be withdrawn in a Policy Year_____________________ (1% to 12%)
Systematic Transfer Option, Choose Target STO Fund India Multi-cap Equity Fund Equity II Fund Emerging Leaders Equity Fund
Large Cap Advantage Fund
Return Protector Option, Choose RPO Fund (India Multi-cap Equity Fund/ Equity II Fund/ Emerging Leaders Equity Fund/ Large Cap
Advantage Fund ) Target Appreciation ____(appriciationPercentage)____ % (5% to 15% in multiple of 1)
@
Only one of ‘Milestone Withdrawal Option’ or ‘Systematic Withdrawal Option’ can be chosen.

For Pension Plans (Linked/Non-Linked)**:

Annuity option at the time of vesting (maturity) (Please mention Annuity option code as mentioned below)
01 Immediate Life Annuity 02 Immediate Life Annuity with 03 Immediate Life Annuity with
Return of Purchase Price Return of Balance Purchase
Price
04 Immediate Life Annuity with Return of Purchase Price on 05 Immediate Joint Life Annuity 06 Deferred Life Annuity with
Critical Illness (CI) or Accidental Total & Permanent with Return of Purchase Price Return of Purchase Price
Disability (ATPD) or Death

Is this pension plan being bought from the proceeds of existing pension plan of the company Yes No
(Note: Only Single Premium option is applicable in such cases)

Fund Allocation (for Unit Linked Pension Plan) Please select the proportion in which you wish to invest your premiums (%)
as per the options available with the product chosen

% %
Pension Debt Fund Pension Nifty Alpha 50 Index Fund

The SFIN (Segregated Fund Index Number) for: Pension Debt Fund is ULIF01605/11/15PENSDEBFND136, Pension Nifty
Alpha 50 Index Fund is ULIF02618/08/25PNALFEQFND136
For Rider(s)
I would like to opt for Rider Plan Option*8 : [ ] Accidental Death Benefit [ ] Accidental Total & Permanent Disability

* Please refer sales brochure for details on option(s)/ Unit Linked Fund(s) available under a particular product.
** The Policyholder will have to select the proportion of annuity to be received as a lump sum and the balance in the form of an annuity as
described above. In case you fail to select the annuity proportion at time of vesting, 100% of vesting amount will be annuitized.

1
Wealth Edge, Alpha Wealth, Promise4Growth; 2 Applicable for Guaranteed Suraksha Kavach;3 Applicable for iSelect Guaranteed Future; 4
Applicable for Guaranteed Fortune Plan; 5 Applicable for Guaranteed Assured INcome; 6Applicable for iSelect Guaranteed Future Plus; 7
Applicable for Promise4Future 8 Applicable for Accidental Benefit Rider (Linked)

Mode of Renewal Premium Payment

Preference for Renewal Premium Payment
Cheque/Demand Draft ✔ Standing Instructions/NACH Credit Card Others________
Please fill Payor Questionnaire , Payor KYC and AML Questionnaire if Payor different than Proposer

Bank Details of Proposer for receiving refund or payments

I hereby request you to transfer all refunds / payments arising from the stage of proposal until the completion of tenure of the policy, directly to the
bank account, details of which are provided herein below.
Note - Please submit relevant supporting documents along with the below details
Account Holder Name First Name :- Madhur Middle Name :- Last Name :- Shrivastava
Bank Name Federal Bank
Account No 77770104758715 IFSC Code FDRL0007777
Branch Address FEDERAL TOWERS,MARINE DRIVE, KOCHI, ERNAKULAM, KERALA - 682031
Account Type ✔ Savings Current NRE NRO
 Declaration and Authorization
•I hereby declare, on my behalf and/or on behalf of Life to be Insured, that the above statements, answers and/or particulars given by me are true
and complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of the Life Insured.
•I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy
of the insurer and that the policy will come into force only after full payment of the premium chargeable.
•I further declare that I will notify in writing any change occurring in the occupation or general health of the Life to be Insured/ proposer after the
proposal has been submitted but before communication of the risk acceptance by the company.
•I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the
person to be insured/ proposer or from any past or present employer concerning anything which affects the physical or mental health of the
person to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured
/proposer has been made for the purpose of underwriting the proposal and/or claim settlement
•I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole
purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
•I/We hereby declare/authorize Company to send me any information relating to my proposals / policies through SMS on the phone
number/email address provided by me.
•I have selected the product on voluntarily basis my needs and affordability and also hereby agree that any failure on my/our part to notify the
Company of the required information or if any of the statements, answers and declarations are found to be fraudulently made or amount to
mis-statement, the said contract shall stand terminated and benefits payable under the Policy will be as per applicable laws including Section 45
of the Insurance Act, 1938, as amended from time to time.
•I authorize the Company to conduct screening/confirmation/ reconfirmation of overall status of my as well as that of the Life to be Insured
including the health status through medical examinations, if required, which may include Laboratory tests, Cardiac, Radiological investigations
and other medical tests including blood tests to detect bacterial/viral/fungal infections. I hereby give my consent to undergo HIV1/2 test by ELISA
method. I am aware that this test is only for screening purposes and not confirmatory for HIV/AIDS.
•I/We authorize the Company to share (within or outside India) my or life to be Insured's information regarding the financial, physical or mental
health together with leave records and employment details of the life to be assured/proposer and details available in my Ayushman Bharat Health
Account (ABHA) from/ with (i) Governmental and/or Regulatory Authority,(ii) Insurance Repositories (iii) CERSAI/ other authentication agencies
(iv) reinsurers//hospitals or diagnostic centers/other insurance companies including any past or present employer for underwriting assessment,
claim investigation/ settlement, KYC authentication (if permitted), offline verification, policy servicing purpose including renewals as per regulatory
framework put in place by the Authority.
•For KYC purposes, I hereby consent or authorize the Company (i) to receive/download the KYC details, information and documents from
CERSAI; and/or (ii) share my KYC details, information and documents with CERSAI.
•I/We declare that the premiums paid/ payable are/will not be generated from the proceeds of any illegal means/criminal activities / offences and
I/we shall abide by and conform to the Prevention of Money Laundering Act, 2002 or any other applicable laws. I understand that in case of
withdrawal of this application by me post undergoing medicals or part thereof, the Company shall return the first premium deposit without any
interest and after deducting the expenses incurred on the medical test/examination, if any.

In case of Thumb Impression, Left Thumb Impression (LTI) for Males, and Right Thumb Impression (RTI) for Female

Signature/Thumb Impression of Life to be Insured

Signature/Thumb Impression of Proposer
(Proposer signature required if Life to be Insured is a minor)

Date: 22/10/2025 Place Gwalior

Digitally signed through OTP on 22-10-2025 at 10:31:38 AM

Foreign Account Tax Compliance Act ("FATCA")/Common Reporting Standards ("CRS") Declaration (Applicable if the proposer is a US
person or is a tax resident outside of India):
i I/we certify that (a) I am taxable as a US person under the laws of the United States of America ("U.S.") or any state or political subdivision
thereof or therein, including the District of Columbia or any states of the U.S., or (b) an estate the income of which is subject to U.S federal
income tax regardless of the source thereof. (This clause is applicable only if the proposer is identified as a US person); or (c) taxable
as a tax resident under the laws of country outside India. (This clause is applicable only if the proposer is a tax resident outside of
India)
ii I/We understand that the Company is relying on the information submitted by me for the purpose of determining my status in compliance
with FATCA/CRS. The Company is not able to offer any tax advice on CRS or FATCA or its impact on me. I/We shall seek advice from
professional tax advisor for any tax questions. I/We agree to submit a new form within 30 days if any information or certification on this form
becomes incorrect. I/We agree that as may be required by domestic regulators /tax authorities, the Company may also be required to
report, reportabledetails to CBDT or close or suspend my policy. I/We certify that I/We provide the information on this form and to the best
of my/our knowledge and belief the certification is true, correct, and complete including the taxpayer identification number.

Signature/Thumb Impression of Life to be Insured

Signature/Thumb Impression of Proposer
(Proposer signature required if Life to be Insured is a minor)

Date: --/--/---- Place _____________________

Declaration by Insurance Intermediary's Representative/Direct Sales Person/Agent, etc

I _____________ have suggested the present product (s) to the Proposer basis the
assessment of suitability thereof to the needs of the proposer and have fully
explainedI/We certify that I/We provide the information on this form and to the best of Signature of Insurance Intermediary's
my/our knowledge and belief the certification is true, correct, and complete including the Representative/Direct Sales Person/Agent, etc
taxpayer identification number.all the features thereof to the Proposer and he/she has
understood same.

Declaration and authorization of Proposer on Bima Applications Supported by Blocked Amount (Bima – ASBA)
As per the IRDAI’s directions, I hereby provide my express consent and authorise Canara HSBC Life Insurance to block an amount as quoted in
this proposal form (including applicable taxes), for the purpose of premium payment towards insurance. I agree and understand that this mandate
shall be valid for a period of (i) 14 days from the date of premium block mandate or (ii) date of acceptance of this proposal, whichever is earlier
and that the blocked amount will be utilised towards premium payment upon proposal acceptance. I further authorise Canara HSBC Life
Insurance to share information with the relevant entities for the purpose of blocking/releasing the premium amount.
Impression, Left Thumb Impression (LTI) for Males, and Right Thumb
Impression (RTI) for Females
Signature/Thumb Impression of Proposer
Date: --/--/---- Place _____________________
The above mandate is as per guidelines specified by NPCI from time to time and is applicable to individual proposers only

Vernacular language/Proposal not filled by Prospect/Illiterate Declaration:

I _________ Son/Daughter of ___________ , adult and residing at _______________________________________ do hereby declare on
solemn affirmation as under: I have read out and fully explained the contents of the proposal form in ______________ language to Mr./Mrs./Ms.
__________________ and he/she has understood the significance of the proposed contract. I have truthfully and correctly recorded the replies
given by the Proposer/Life to be Insured and that the Proposer/Life to be Insured has affixed the signature/thumb impression above, after fully
understanding the contents thereof. Solemnly affirmed at __________________________ on ________________________
I _________________ (Proposer) hereby declare that I have understood the
Signature of Insurance Intermediary's Representative/Direct
questions and answers of the proposal form as explained by Insurance
Sales Person/Agent/Declarant
Intermediary's Representative/Direct Sales Person/Agent/Declarant

Signature/Thumb Impression of Proposer

 YOUR COMMUNICATION ADDRESS IS VERY IMPORTANT FOR BETTER SERVICE. PLEASE CHECK IT THOROUGHLY
BEFORESIGNING

Section 41 of Insurance Act, 1938 (as amended from time to time)

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance
in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may
be allowed in accordance with the published prospectuses or tables ofthe insurer.
Section 45 of 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 may be called in question at any time within three years from the date of issuance of the policy or the date of
commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided
that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the
grounds and materials on which such decision is based.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud if the insured
can prove that the misstatement of a or suppression of a material fact was true to the best of his knowledge and belief or that there was no
deliberate intention to suppress the fact or that such mis-statement of or suppression of a material fact are within the knowledge of the insurer: -
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of
commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground that any statement
of or suppression of a fact material to the expectancy of the life of the insured was incorrectly madein the proposal or other document on the
basis of which the policy was issued or revived or rider issued: Provided that the insurer shall have to communicate in writing to the insured or the
legal representatives or nominees or assignees of the insured the grounds and materials on which such decision to repudiate the policy of life
insurance is based: Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and
not on 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 sections 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 insuredwas
incorrectly stated in the proposal.

Proposal Acknowledgment Proposal Number: 7500224747

I, Mr/Ms ___________________ have received the proposal for life insurance along with (Rs.) _______________________
from Mr/Ms __________________ towards proposal deposit by the way of Cash / Cheque / DD No. ___________ drawn on
______________ dated _____________ with Canara HSBC Life Insurance Company Limited, ___________________ branch.
This slip is not your premium receipt. The premium receipt will be issued only on receipt of premium by the Insurer and upon
application of the premium to your policy subject to acceptance of risk. Receipt of completed proposal and initial premium does
not create any obligation upon the insurer to underwrite the risk. Risk under the policy will not commence till the Insurer
accepts the proposal, underwrite the risk and communicates to you the acceptance of the risk on this proposal by issuing the
policy

Details of Insurance Intermediary's representative/Direct Sale Person/Agent

Name ____________
Code ____________
Date 22/10/2025 Signature
 Canara HSBC Life Insurance Company Limited
IRDAI Regn. No. 136
Head Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: 8th Floor, Unit No. 808 - 814, Ambadeep Building, Plot No.14, Kasturba Gandhi Marg, New
Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825

Toll free at 1800-103-0003 / 1800-891-0003 SMS at 9779030003

E-mail us at [email protected] Visit us at our website www.canarahsbclife.com
 AML Addendum
(To be filled in for Proposer)

Proposal Number 7500224747

Name of Proposer/LA/Payor(as applicable) Madhur Shrivastava

1. Former / Other name (if any)- Mr. / Mrs. / Ms? Yes ✔ No

(Supporting documents are required for former / other name)

2. Have you changed your Country / City of residence in last 3 years Yes ✔ No

(i) If answered Yes for Q2, Please provide details

(ii) If answered Yes for Q2, Please mention date moved to the new
Country / City

3. Have you held any other Nationalities in the past Yes ✔ No

If answered Yes for Q3, Please provide your previous Nationalities

(a)

(b)

4. 1 2 3 4

Country of tax residence

(if taxes are/are also filed outside India)

Tax Identification No.

5. Government issued Identification number.

(Not required if any one of these are submitted with application. Aadhaar, PAN, Driving License, Voter ID, Passport etc.,)

Date :

Signature 22/10/2025
(Proposer / LA / Payor)

UW/AMLADD/Version 1.1