Application Verification Form

APPLICATION DETAILS
Application No. 1100113918860
Type of Insurance Plan Protection
Name of Insurance Plan HDFC Life Click 2 Protect Super
Premium Payable Rs.1,54,027

Frequency Annual

Premium Payment Term 5 year(s)

Sum Assured Rs.90,00,000

Declarations
Have you filled the electronic proposal form or has a third party or sales official assisted you? YES
Do you agree to the Illustration / suitability questionnaire signed by you / received by you on your email ID with above application number? YES

Do you agree to the terms & conditions mentioned in the electronic proposal form? YES
Have you understood these policy details: Death Benefit YES

Have you understood the policy provisions with regards to pre-closure/surrender? YES
This application is for a new insurance policy & is not linked with any other financial product like credit card/loan etc YES
Are you a tax resident of India only as per the Indian income tax law? YES

I/we would like to receive Dematerialized policy NO

I / We understand that I / We may receive calls from HDFC Life in relation to this proposal for insurance or the resulting Policies.

I / We give my consent to HDFC Life to make such calls even when I am / We are registered on NDNC registry. I / We allow HDFC Life to use my Bank account details
shared by me via cancelled cheque or NEFT details provided by Sourcing Channel for any future payouts.

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/us and HDFC Life.

I/ We give consent to allow to furnish my credentials / information (address, contact no., email ID, loan details, income & nominee) as per their/his/ her records & vice versa. YES

I / We declare that the content of the form and document has been fully explained to me and I / We have fully understood the significance of the proposed contract.

I / We agree and understand that the insurance plan purchased is on the basis of the need analysis done and as suggested by Suitability Questionnaire.(if applicable)

I / We hereby agree that the recommended product is based on the information provided by me which was part of the Suitability Questionnaire.

ADDITIONAL DETAILS
"I/ We hereby solemnly affirm and declare that (i) I/ we have understood all the questions mentioned above and I/we have correctly disclosed all information relating to my/ our health and
habits; and (ii) details of all my/ our life insurance policies issued, declined or postponed including any policy application that has been submitted to any insurer and is under process has
been declared in this application. I/ We hereby understand and agree that any non-disclosure or misstatement of the above can lead to cancellation of the policy or repudiation of a claim
made under this policy in line with the applicable regulatory provisions."

Product type: Non-Linked Non-Participating Term Insurance Plan.

If you have opted for rider. Kindly refer to the terms & conditions post receipt of policy document.

Free look-in period: Within 30 days from the receipt of the policy document.

#Life insurance is a standalone product and is neither a fixed deposit nor loan nor is it linked to any other banking products
# Purchase of this policy is voluntary in nature
# Refer to the policy document for more details
"I agree that the above confirmation for policy conversion is an independent decision without any inducement."
PAYMENT DETAILS
Initial Payment has been made from account/Debit Card/Credit Card that belongs to: self

Mode of Payment online/offline credit card

This Application form has been digitally authenticated/signed by customer through OTP xxxx sent on Mobile number 9351XXXXXX on 2024-12-13 15:56:09

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