Duplicate

PART A
Welcome to Max Life Insurance
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Date 10-Nov-2022
To MR. K SASIDHARAN ADIYODI
SAIF RASHID AL HURAIZ BLDG
WATER SUB METER (FLAT 312) 318 47 AL KARAMA
STREET DM 79
PREMISE NUMBER 318131900 PREMISE TYPE
RESIDENTAL FLAT
DUBAI 34666
UAE UNITED ARAB EMIRATES
Branch: X0159
Policy no.: 116319534
Telephone: 1501400175, --
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Welcome Dear MR. K SASIDHARAN ADIYODI,
Thank you for opting for Max Life Smart Wealth Plan (A Non-Linked Non-Participating Individual Life Insurance Savings Plan).
We request you to go through the enclosed policy contract.
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What to do in On examination of the Policy, if you notice any mistake or error, proceed as follows:
case of errors 1. Contact our customer helpdesk or your agent immediately at the details mentioned below.
2. Return the Policy to us for rectifying the same.
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Cancelling the In case you are not satisfied with the Policy, you have the option to cancel it by returning the original copy with a written request,
Policy stating the objections/reasons for such disagreement, to us within the Freelook period of 15 days from the date of receiving the
Policy document.

Result: Upon return, the Policy will terminate forthwith and all rights, benefits and interests under the Policy will cease
immediately. We will refund only the Premiums received by us after deducting the proportionate risk premium for the period of
cover, stamp duty paid and the expenses incurred on medical examination of the Life Insured, if any.
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Long term We are committed to giving you honest advice and offering you long-term savings, protection and retirement solutions backed by
protection the highest standards of customer service. We will be delighted to offer you any assistance or clarification you may require about
your Policy or claim-related services at the address mentioned below. We look forward to being your partner for life.
Yours Sincerely,
Max Life Insurance Company Limited

R Krishnakumar Digitally signed by DS MAX LIFE INSURANCE COMPANY LIMITED 1

Executive Vice President - Head of Operations Date: 2025.08.03 15:10:23 IST
Reason: Max Life Insurance
Location: 90C, Gurugram

AGENT NAME : M/S. AXIS BANK LTD KANNUR (911883), PH NO.:

0497-2760646, ADDRESS: CW-35-3773/A, Ground Floor, Zuhara Arcade,
Arat Road,, Kannur,
NB13
Max Life Insurance Company Limited
Plot No. 90A, Sector 18, Gurugram, 122015, Haryana, India
Phone 4219090 Fax 4159397 (From Delhi and Other cities: 0124) Customer Helpline: 1860 120 5577
Regd. Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr, Punjab -144 533
Visit Us at: www.maxlifeinsurance.com E-mail: [email protected]
IRDAI Registration No: 104 Corporate Identity Number: U74899PB2000PLC045626 .

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Key Feature Document for Max Life Smart Wealth Plan- Lumpsum
Plan UIN A Non-Linked Non-Participating Individual Life Insurance Savings Plan UIN: 104N116V08
Unique Ref. No. 116319534
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Introduction This document is the summary of important points in your policy. You must read this to understand your policy
better.
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Policy Benefits The table below explains the benefits if the Life Insured survives the Policy Term:
If the life insured If you Then you receive
lives Pay all the Premiums applicable in your policy Guaranteed Sum Assured on Maturity plus Accrued
Guaranteed Additions, if any and the policy terminates
thereafter
Do not pay the complete Annualised Premium for first No benefits and the life cover ceases, however, You can
two Policy Years revive the Policy within five years from the due date of
the first unpaid Premium by paying the Premiums due
and late fee.
Do not pay the renewal premium in the third year or Reduced Paid Up Death Benefit or Reduced Paid Up
thereafter and do not surrender the Policy Maturity Benefits as the case may be in terms of the
Policy.
Surrender the Policy after paying all due Premiums for Surrender value and the Policy will terminate thereafter.
first 2 (Two) Policy Years

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If the life insured If the Life Insured expires during the Policy Term and we have received all due Premiums, we will immediately
expires pay the death benefit, the highest of the following:

• 11 times the (Annualised Premium* plus Underwriting Extra Premiums***, if any)

• 105% of sum of Total Premiums Paid**, Underwriting Extra Premiums*** and loadings for modal premiums
as on the date of death of Life Insured
• The absolute amount assured to be payable on death under these variants is equal to the Total Premiums Paid
accumulated monthly at an interest rate of 8% p.a.

*"Annualised Premium" means Premium amount payable during a Policy Year chosen by Policyholder, excluding
Underwriting Extra Premium, loading for modal premium, Rider Premiums and applicable taxes, cesses or levies
if any;

** "Total Premiums Paid" means the total of all Premiums received, excluding Underwriting Extra Premium,
loading for modal premium, Rider Premiums, and applicable taxes, cesses or levies, if any.

***"Underwriting Extra Premium" means an additional amount charged by Us, as per Underwriting Policy, which
is determined on the basis of disclosures made by Policyholder in the Proposal Form or any other information
received by Us including medical examination report of the Life Insured
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Managing Your Policy - Frequently Asked Questions
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What you need to You need to
do? • Pay Premiums on time for the entire Premium Payment Term. There are various easy and convenient payment
options for you to choose from. To know more about payment options, log on to www.maxlifeinsurance.com,
and
• Read the details of the Policy document, including the Proposal Form, to ensure the accuracy of information.
For any error you observe, contact us for correction
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How can you manage Manage your policy under the Customer Service section by visiting www.maxlifeinsurance.com to get easy access
your policy? to the following self-service options:
• Access Policy statements, receipts and Premium due information
• Update your contact details
• Pay renewal Premiums online
Note: For any support or claim-related query, you can reach us at 1860 120 5577 or (0124) 4219090 or
[email protected]
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Premium Payment This variant provides limited and regular pay options to the policyholder. In limited pay, policy term is different
Term/ Policy Term from premium payment term and in regular pay, policy term is equal to premium payment term.
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What happens if you To ensure continuous life insurance cover, please pay your Premium on time. If for any reason, you are unable
delay your premium to pay by the due date, you have a grace period of 15 days from the due date of the unpaid premium for monthly
payment? premium payment mode and 30 days from the due date of the unpaid premium for annual premium payment modes,
within which you can pay without any late fee.

Note: During the Grace Period, the insurance cover continues. If the Life Insured dies during this period, we will
pay the Death Benefit after deducting the unpaid Premium, if any.
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Can you take a loan Yes, you may take a loan under this Policy subject to a maximum of 50% of Surrender Value as per the applicable
against the policy? terms and conditions of the Policy contract.
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How can you cancel If your Policy does not meet your objective, you may contact us to understand the Policy benefits. If you still feel
your policy? the need to cancel your Policy, you have an option to cancel it within the free look period of 15 days from the
day you receive the Policy documents.

Note: If you have bought this Policy from the Distance Marketing, you have a free look period of thirty days.
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How can you revive You may Revive your Policy within five years from the due date of the first unpaid Premium, once you
your policy? • provide us with a written request to Revive the Policy
• pay all overdue Premiums (along with the applicable taxes, cesses and levies, if any) along with late fee, and
• produce evidence of insurability of the Life Insured.
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Taxes and Others - Frequently Asked Questions

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Tax benefits Tax benefits may be available as per the prevailing tax laws.
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Exclusions Suicide
In the event Life Insured commits suicide, within twelve months from the Date of Commencement of risk or
Revival, all risks and benefits under this Policy shall cease and no benefits will be payable. We shall only pay
either the following to the Claimant:
• higher of the Surrender Value or total premiums paid till date of death (plus underwriting extra premiums paid
plus loadings for modal premiums, if any) if the Policy has acquired a Surrender Value; or
• Total premiums paid (plus underwriting extra premiums paid plus loadings for modal premium, if any), if the
Policy has not acquired a Surrender Value.

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 Waiting period
In case this policy is sourced through a Point of Sale person, in such cases, there is a waiting period of 90 days from
the Date of Commencement of Risk of this Policy ("Waiting Period"). In case of death (for other than accidental
death only) during this Waiting Period, 100% of the total premiums paid till the date of death will be payable
excluding applicable taxes, cesses, levies, if any. The Death Benefit will not be payable.
In case of death of Life Insured due to accident, the Waiting Period is not applicable, and Death Benefit shall be
payable. The Waiting Period is not applicable in case of revival of the Policy.
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Disclaimers The aim of this document is to summarize the key features of your policy and does not replace the policy, in any
way. In case of any discrepancy between the policy contract and this document, the terms and conditions of the
policy contract shall prevail.
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 POLICY PREAMBLE

MAX LIFE INSURANCE COMPANY LIMITED

Regd. Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr, Punjab -144533

Max Life Smart Wealth Plan

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

UIN [104N116V08]

Max Life Insurance Company Limited has entered into this contract of insurance on the basis of the information given in the Proposal Form
together with the Premium deposit, statements, reports or other documents and declarations received from or on behalf of the Proposer for
effecting a life insurance contract on the life of the person named in the Schedule.

We agree to pay the benefits under the Policy on the happening of the insured event, while the Policy is in force subject to the terms and
conditions stated herein.

Max Life Insurance Company Limited

Place of Issuance :Gurugram, Haryana

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POLICY SCHEDULE

Policy: Max Life Smart Wealth Plan Type of Policy: A Non-Linked Non-Participating Individual Life
Insurance Savings Plan
UIN: 104N116V08 Office: AXIS BANK LTD Kannur
Policy No./ Proposal No.: 116319534 Client ID: 0005266517

Date of Proposal: 23-Oct-2022

Policyholder/Proposer : Mr. K Sasidharan Adiyodi Age Admitted: Yes

PAN: ABTPA7408E Gender: Male

Identification Source & ID No.: NA Tel No./Mobile No.: / 1501400175

Relationship with Life Insured: Daughter Email: [email protected]

Date of Birth: 11-Apr-1964

Address(For all communication purposes):

SAIF RASHID AL HURAIZ BLDG WATER SUB METER (FLAT
312) 318 47 AL KARAMA STREET DM 79 PREMISE NUMBER
318131900 PREMISE TYPE RESIDENTAL FLAT
DUBAI 34666 UAE UNITED ARAB EMIRATES
Life Insured: Ms. Vishnupriya Sasidharan Age Admitted: Yes

Identification Source & ID No.: NA Gender: Female

Date of Birth: 16-Nov-2001

Age: 20 years
Address(For all communication purposes): SAIF RASHID AL
HURAIZ BLDG
WATER SUB METER (FLAT 312) 318 47 AL KARAMA
STREET DM 79 PREMISE NUMBER 318131900 PREMISE
TYPE RESIDENTAL FLAT
DUBAI 34666
UNITED ARAB EMIRATES

Nominee(s): Guardian/ Appointee (if Nominee is minor): N.A.

Nominee (s)Name Relationship Date of Birth Age: %
of Nominee(s) Of Nominee: share
with
Policyholder:
Same as proposer
Date of Commencement of Risk/Inception of Policy: 21-Oct-2022 Premium Payment mode: Annual

Date of Issuance of Policy: 31-Oct-2022

Details of the Riders, if any: NA Policy Variant: Lump Sum
Date on which Survival Benefit is payable: N/A
Premium Payment Method: ECS Bill Draw Date: 23RD

Bank Name: AXIS BANK

Bank Account Number: 159010100040008

Bank Account Details for Pay outs: Bank Name: AXIS BANK

Bank Account Number: 159010100040008

Agent's name/ Intermediary name: M/S. AXIS BANK LTD Agent's code / Intermediary code: 911883
KANNUR
Agent's/ Intermediary License No.: CA0069
Email: NA
Mobile/Landline Telephone Number: 0497-2760646
Address:
CW-35-3773/A, Ground Floor, Zuhara Arcade, Arat Road,,
Kannur 670001
Details of Sales Personnel (for direct sales only): N/A
Existing Customer Discount (available for first policy year only): No

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 List of Maturity Death Benefit Guaranteed Guaranteed Policy Premium Annualised Underwriting GST** and Modal Factor Total Due Date
Coverage Date payable Sum Assured Additions (as Term Payment Premium Extra any other D Premium when
on Maturity per Clause Term A Premium taxes, cesses along with Premium
(INR) B & levies applicable is payable/
1.2 of Part C) (INR) (INR) C Date
(INR) taxes, cesses when the
and levies Last
payable as Premium
per Premium is payable
payment
mode selected
E=
[(A+B+C)*D]
(INR)
Max Life 21st of Oct
Smart Wealth 21-Oct-2034 As per Clause 44,00,000.00
1 of Part C 2201601 12 08 5,00,000.16 NA 11,250.00 1 5,11,250.16 every year;
Plan 21-Oct-2029

**GST includes IGST, SGST, CGST, UGST (whichever is applicable) and applicable cesses

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PART B
DEFINITIONS
The words and phrases listed below will have the meaning attributed to them wherever 26. "Reduced Paid Up Death Benefit" means an amount equal to the Death
they appear in the Policy unless the context otherwise requires. Benefit as specified in Clause 1 of Part C (applicable at the time of Premium
1. "Age" means Life Insured's age on last birthday as on the Date of discontinuance) multiplied by the resultant of sum of the Total Premiums Paid
Commencement of Risk or on the previous Policy Anniversary, as the case may plus loadings for modal premiums (if any) received by Us under the Policy,
be; divided by the sum of total Premiums payable (excluding Underwriting Extra
2. "Annualised Premium" is the amount specified in the Schedule, and means Premium and Rider Premium) by You plus loadings for modal premiums
the Premium amount payable during a Policy Year chosen by You, excluding payable (if any) under the Policy;
Underwriting Extra Premiums, loadings for modal premiums, Rider Premiums 27. "Reduced Paid Up Mode" means the Policy with reduced paid up benefits as
and applicable taxes cesses and levies, if any; specified under Clause 1.3 of Part C;
3. "Appointee"/"Guardian" means the person named by You (as applicable and 28. "Reduced Paid Up Guaranteed Sum Assured on Maturity" means an
registered with Us in the Schedule who is authorised to receive and hold in trust amount equal to the Guaranteed Sum Assured on Maturity multiplied by the
the benefits under this Policy on behalf of the Nominee/(s), if the Nominee/(s) resultant of sum of the Total Premiums Paid plus loadings for modal premiums
is/are less than Age 18 on the date of payment of the such benefit; (if any) received by Us under the Policy divided by the sum of total Premiums
4. "Claimant" means You (if You are not the Life Insured), Nominee(s) (if payable (excluding Underwriting Extra Premium and Rider Premium) by You
valid nomination is effected), assignee(s) or their heirs, legal representatives or plus loadings for modal premiums payable (if any) under the Policy;
holders of a succession certificates in case Nominee(s) or assignee(s) is/are not 29. "Revival" means restoration by Us of the Policy, which was discontinued due
alive at the time of claim; to non-payment of Premium, by Us with all the benefits stated in the Policy,
5. "Date of Commencement of Risk/ Inception of Policy" means the date as upon the receipt of all the due Premiums and other charges / late fee as provided
specified in the Schedule, on which the insurance coverage / risk under the in Clause 3 of Part D of the Policy;
Policy commences; 30. "Revival Period" means a period of 5 (Five) consecutive years from the due
6. "Force Majeure Event" means an event by which performance of any of Our date of the first unpaid Premium, during which period You are entitled to revive
obligations are prevented or hindered as a consequence of any act of God, State, the Policy which was discontinued due to the non-payment of Premium;
strike, lock-out, legislation or restriction by any government or other authority 31. "Rider" means benefits, which are in addition to basic benefits under the
or any circumstance beyond Our anticipation or control during continuance Policy;
whereof the performance of Our obligations under this Policy shall remain 32. "Rider Premium" means the premium amount payable in respect of a Rider
wholly or partially suspended; applicable under the Policy and is the amount specified in the Schedule;
7. "Freelook" means a period during which, subject to the Clause 6 Part D of 33. "Schedule" means the policy schedule and any endorsements attached to and
the Policy, You have an option to return the original Policy to Us by stating the forming part of the Policy and if any updated Schedule is issued, then, the
objections/reasons for such disagreement in writing; Schedule latest in time;
8. "Grace Period" means the time granted by Us from the due date for the 34. "Surrender Value" means an amount payable on surrender of this Policy, in
payment of Premium, without any penalty or late fee, during which time the accordance with Clause 1 of Part D;
Policy is considered to be in-force with the risk cover without any interruption, 35. "Total Premiums Paid" means the total of all Premium received under the
as per the terms and conditions of the Policy. The grace period is a period of Policy, excluding Underwriting Extra Premium, loadings for modal premiums,
15 (Fifteen) days from the due date of the first unpaid Premium for monthly Rider Premium, and applicable taxes, cesses or levies (if any).
Premium payment mode and 30 (Thirty) days from the due date of the first 36. "Underwriting Extra Premium" means an additional amount mentioned
unpaid Premium for annually, semi-annually or quarterly premium payment in the Schedule and charged by Us, as per Underwriting Policy, which is
modes; determined on the basis of disclosures made by You in the Proposal Form or
9. "Guaranteed Addition" means an amount, as specified in the Schedule, the any other information received by Us including medical examination report of
same shall accrue and shall be payable by Us in accordance with Clause 1.2.3 the Life Insured, if any;
of Part C; 37. "Underwriting Policy" means the underwriting policy approved by Our board
10. "Guaranteed Sum Assured on Maturity" means the guaranteed amount as of directors;
specified in the Schedule calculated as per Clause 1.2 of Part C, payable on 38. "We", "Us" or "Our" means Max Life Insurance Company Limited; and
the Maturity Date, if the Life Insured is alive on the Maturity Date and all due 39. "You" or "Your" means the policyholder as named in the Schedule.
Premiums have been received by Us;
11. "Guaranteed Surrender Value" means the Surrender Value computed in PART C
accordance with Clause 1 of Part D, which is guaranteed by Us; POLICY FEATURES, BENEFITS AND PREMIUM PAYMENT
12. "IRDAI" means the Insurance Regulatory and Development Authority of 1. BENEFITS
India; 1.1. Death Benefit
13. "Lapsed Policy" means a Policy which has not acquired the Surrender Value If the Life Insured dies during the Policy Term, provided the Policy is in force
and where the due Premium has not been received for any of the first two Policy and is not a Lapsed Policy or in Reduced Paid Up Mode, on the date of death
Years; of the Life Insured, We will pay a lump sum guaranteed "Death Benefit"
14. "Life Insured" means the person named in the Schedule, on whose life the which will be highest of the following:
Policy is effected; (i) 11 (Eleven) times the sum of Annualised Premium and the
15. "Maturity Date" means the date specified in the Schedule, on which the Policy Underwriting Extra Premium (if any);
Term expires; (ii) 105% (One Hundred Five percent) of sum of Total Premiums Paid plus
16. "Modal Factor" means the applicable factor specified in the Schedule, which loadings for modal premiums and Underwriting Extra Premium (If any)
is used by Us for determining the Premium. The Modal Factors for this Policy as on the date of death of the Life Insured; or
are as follows: i) for annual Premium payment mode - (1.0); ii) for monthly (iii) Absolute amount equal to the Total Premiums Paid accumulated
Premium payment mode - (0.09); monthly at an interest rate of 8% p.a.
17. "Nominee" means the person named in the Policy Schedule who has been 1.2. Maturity Benefit
nominated by You (only if You are the Life Insured), in accordance with Section 1.2.1. If the Life Insured has survived until the Maturity Date, provided the
39 of the Insurance Act, 1938 as amended from time to time to receive benefits Policy is in force and is not a Lapsed Policy or in Reduced Paid Up
in respect of this Policy; Mode on the Maturity Date, then, We shall pay the sum of Guaranteed
18. "Policy" means the contract of insurance entered into between You and Us Sum Assured on Maturity and the accrued Guaranteed Additions.
as evidenced by this document, the Proposal Form, the Schedule and any 1.2.2. The Guaranteed Sum Assured on Maturity payable shall be calculated
additional information/document(s) provided to Us in respect of the Proposal in accordance with the following:
Form along with any written instructions from You subject to Our acceptance Guaranteed Sum
of the same and any endorsement issued by Us; Policy Term
Assured on Maturity
19. "Policy Anniversary" means the annual anniversary of the Date of 10 years 110% x Annualised Premium
Commencement of Risk; 12 years x Premium Payment Term
20. "Policy Term" means the term of this Policy as specified in the Schedule
15 years 140% x Annualised Premium
during which the Policy coverage continues;
16 years x Premium Payment Term
21. "Policy Year means a period of 12 (Twelve) months commencing from the
Date of Commencement of Risk and every Policy Anniversary thereafter; 160% x Annualised Premium
20 years
22. "Premium" means an amount specified in the Schedule, payable by You, x Premium Payment Term
by the due dates to secure the benefits under the Policy, excluding applicable
taxes, cesses and levies, if any; 1.2.3. Guaranteed Additions: Guaranteed Additions will accrue under the
23. "Premium Payment Term" means the term specified in the Schedule, during Policy at the end of each of the last 4 (Four) Policy Years provided
which the Premiums are payable by You; that the Policy is in force and is not a Lapsed Policy or in Reduced
24. "Proposal Form" means the form filled in and completed by You for the Paid Up Mode, on the date the Guaranteed Addition becomes due.
purpose of obtaining insurance coverage under the Policy; The accrued value of Guaranteed Additions shall be payable on the
25. "Proposer" is a person, who proposes for insurance on and has an insurable Maturity Date. In case of Surrender, the Surrender Value of accrued
interest in the life of the Life Insured. However, in case the Life Insured is a Guaranteed Additions shall be payable at the time of surrender of the
minor, the Proposer can only be either a parent or a legal guardian. Policy.

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 1.3. Reduced Paid Up Benefits 1.7. Special Surrender Value
If this Policy has acquired a Surrender Value as specified under Clause 1 of 1.7.1. Special Surrender Value will be the amount equal to the sum of the
Part D, then, in the event of non-payment of the due Premiums by You to Special Surrender Value of base Policy plus Special Surrender Value
Us, on the expiry of the Grace Period this Policy will not become a Lapsed of accrued Guaranteed Additions, wherein:
Policy and will continue under Reduced Paid Up Mode unless revived. A a. Special Surrender Value of base will be an amount equal to
Policy under the Reduced Paid Up Mode will be free from all liabilities of Special Surrender Value factor multiplied by the Total Premiums
payment of future Premiums to Us. If this Policy is under Reduced Paid Up Paid; and,
Mode, then, the benefits payable shall be as follows: b. Surrender Value of accrued Guaranteed Additions will be
1.3.1. Reduced Paid Up Death Benefit the amount equal to the accrued Guaranteed Additions multiplied
If the Life Insured dies during Policy Term, We will pay the Reduced by the Special Surrender Value factor for accrued Guaranteed
Paid Up Death Benefit to the Claimant. Additions.
1.3.2. Reduced Paid Up Maturity Benefit 1.7.2. It may be noted that the Special Surrender Value factor for base as well
If the Life Insured has survived until the Maturity Date, We shall as for accrued Guaranteed Additions may be revised by Us, subject to
pay the Reduced Paid Up Guaranteed Sum Assured on Maturity plus prior approval from IRDAI.
accrued Guaranteed Additions (if any). It is clarified here that the 1.8. Surrender Value for a Reduced Paid Up Mode Policy: The Surrender
Guaranteed Additions accrued under the Policy until the date on which Value of Reduced Paid Up Mode Policy will also be determined using the
the Policy moves to Reduced Paid-Up Mode shall be payable. above methodology and factors.
2. PREMIUMS 2. LOANS
2.1. You can pay the Premiums annually or on monthly basis, as per the Premium 2.1. Once this Policy has acquired the Surrender Value, then, You will be eligible
payment mode chosen by You. for grant of loans from Us.
2.2. You can pay Premium at any of Our offices or through Our website 2.2. The minimum amount of loan which can be granted by Us under this Policy is
www.maxlifeinsurance.com or by any other means, as informed by Us. Any INR 10,000 (Rupees Ten Thousand). In no event shall the maximum amount
Premium paid by You will be deemed to have been received by Us only after of loan which can be granted under this Policy during the Policy Term exceed
the same has been realized and credited to Our bank account. 50% (Fifty percent) of the Surrender Value payable under this Policy, subject
2.3. The Premium payment receipt will be issued in Your name, which will be to such terms and conditions as may be determined by Us from time to time.
subject to realization of cheque or any other instrument/medium. 2.3. If You have obtained a loan under this Policy, then, You are required to
3. GRACE PERIOD pay interest on such loan. The interest on the loan will be compounded and
3.1. The Premium is due and payable by the due date specified in the Schedule. applied annually on the Policy Anniversary at the rates as prescribed by Us
If the Premium is not paid by the due date, You may pay the same during the at the time of taking the loan.
Grace Period without any penalty or late fees. 2.4. The loan interest rate shall be equal to applicable 'RBI Bank Rate' plus 3.0%.
3.2. The insurance coverage continues during the Grace Period. However, if the The current loan interest rate is 9.90% p.a. compounded annually and is
overdue Premium is not paid even in the Grace Period, and the Life Insured effective 1st July 2019 based on 'RBI Bank Rate' of 7.0% p.a. prevailing as at
dies, then, We will pay the Death Benefit under this Policy after deducting st
5th April 2016. The 'RBI Bank Rate' for the financial year ending 31 March
the due Premium (if any) till the date of death. (every year) will be considered for determining the loan interest rate and the
4. SURVIVAL BENEFIT same shall be made effective w.e.f. 01st July every year. The loan interest rate
No survival benefits are payable under this Policy.
is revised only if the 'RBI Bank Rate' changes by 1% or more from the 'RBI
Bank Rate' used to determine the prevailing loan interest rate (reviewed on
PART D
every 31st March). For further details and the loan interest rate applicable as
POLICY SERVICING CONDITIONS
on date, please refer to our website www.maxlifeinsurance.com. Any change
1. SURRENDER
in the basis of determination of the above interest rate, the same shall be with
1.1. This Policy shall acquire a Surrender Value provided all the due Premiums
prior approval of IRDAI.
for the first 2 (Two) Policy Years have been received in full and applied by
2.5. In case outstanding loan amount including accumulated interest on such
Us on or after the due dates.
loan exceeds 95% of the Surrender Value or the remaining Policy Term is
1.2. You may request in writing to surrender the Policy at any time but You
6 months (whichever is earlier), We will send You a communication for
will get the Surrender Value only if the Policy has acquired the Surrender
repayment of loan along with the accrued interest.
Value. On receipt of such request, the Surrender Value prevailing on the
2.6. If the loan amount granted to You and the accumulated interest on such loan
date of request for the surrender of this Policy shall be payable by Us and
exceeds the Surrender Value, this Policy will terminate. At the end of the
thereafter no other benefits under this Policy shall be payable. Once the
Policy Term, in case of non-repayment of loan, the excess of Surrender Value
Surrender Value is paid, the Policy shall terminate. If the Policy has not
over the loan amount along with accrued interest shall be returned to You.
acquired Surrender Value, then, no amount shall be payable by Us.
2.7. Upon grant of a loan under this Policy, this Policy shall automatically be
1.3. The Surrender Value payable will be subject to the condition that there are
assigned in Our favour, till the time the entire loan amount including interest,
no statutory or other restrictions to the contrary.
any fees or dues towards such loan has been repaid to Us. On repayment
1.4. The Surrender Value will be equal to the higher of Guaranteed Surrender
of the entire loan and accumulated interest to Us, if any, this Policy will be
Value or Special Surrender Value.
reassigned to You.
1.5. Once You have surrendered the Policy, the same cannot be reinstated.
2.8. We reserve the right to recover the outstanding loan along with the accrued
1.6. Guaranteed Surrender Value
interest from the benefits payable in the case of surrender or maturity or death
1.6.1. Subject to Clause 1.1 of Part D, the Guaranteed Surrender Value will
of the Life Insured, by deducting the appropriate amounts from the benefits
be determined in the Policy Year in which the surrender is effected
payable on happening of such events.
and shall be equal to Guaranteed Surrender Value of the base Policy
3. REVIVAL OF POLICY
plus Guaranteed Surrender Value of accrued Guaranteed Additions,
3.1. A Lapsed Policy or a Policy under Reduced Paid Up Mode can be revived
wherein:
as per Underwriting Policy, within the Revival Period:
a. Guaranteed Surrender Value of base Policy will be an amount
3.1.1. on receipt of Your written request to Revive the Policy by Us;
equal to the Guaranteed Surrender Value factors (as specified
3.1.2. if You produce an evidence of insurability (in form of declaration of
in the Table 1 below) multiplied by the resultant of the Total
health condition and/or relevant medical reports) of Life Insured at
Premiums Paid and loadings for modal premiums (if any); and
Your own cost which is acceptable to Us; and
b. Guaranteed Surrender Value of accrued Guaranteed
3.1.3. on payment of all overdue Premiums (along with the applicable taxes,
Additions will be an amount equal to the 30% of such accrued
cesses and levies, if any) to Us with late payment fee as may be
Guaranteed Additons (if any).
determined by Us from time to time (in the manner described here in
1.6.2. Guaranteed Surrender Value factors are expressed as a percentage (%)
below) as on the date of Revival. Currently the applicable late fee is
of sum of Total Premiums Paid and loadings for modal premiums (if
as below:
any) shall be as per table below:

Table 1 - Guaranteed Surrender Value factors No. of days Revival Late Currently
between date of Fee Basis Applicable
Policy Year % of (Total Premiums Paid plus
Revival and date Revival Late Fee*
of Surrender loadings for modal premiums (if any)
of lapse of Policy
1 NIL
0-60 Nil 0.00%
2 30%
RBI Bank Rate +
3 35% 1% p.a. compounded
4-7 50% 61-180 5.65%
annually on
Graduating linearly from 50% to due Premiums
90% during the last two Policy Years RBI Bank Rate +
8+ Minimum (50% + [(40% x 3% p.a. compounded
(N-7)) /(Policy Term - 8)], 90%) >180 7.65%
annually on
N : Year of Surrender due Premiums

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 st 8. RISK COVERAGE FOR MINOR AND VESTING ON ATTAINING
*Note: The current applicable revival late fee effective as on 1 July
st MAJORITY
2020 and is based on RBI Bank rate of 4.65% p.a. prevailing as at 31 The risk coverage for the minors will start from the Date of Commencement
st of Risk. In case the Life Insured is a minor, the Policy will automatically vest
March 2020 The 'RBI Bank Rate' for the financial year ending 31
March (every year) will be considered for determining the revival late in him/her on his/her attaining the age of majority. However, the Life Insured
st on attaining the Age of majority, will be required to provide all the requisite
fee and the same shall be made effective w.e.f. 01 July every year. information (including his address, contact details, bank account details, etc.) and
The revival late fee is revised only if the 'RBI Bank Rate' changes by other documents as specified by Us to enable Us to pay the benefits under this
1% or more from the 'RBI Bank Rate' used to determine the prevailing Policy.
revival late fee (reviewed on every 31st March). For further details and
the revival late fee applicable as on date, please refer to our website PART E
www.maxlifeinsurance.com. POLICY CHARGES
3.2. The Revival of the Lapsed Policy or a Policy under Reduced Paid Up Mode APPLICABLE FEES/ CHARGES UNDER THE POLICY
will take effect only after We have approved the same in accordance with This Policy is a non-linked non-participating individual life insurance savings plan
Our Underwriting Policy and communicated Our decision to You in writing. and therefore, Part E is not applicable to this Policy.
All original benefits such as Guaranteed Additions (if any), Death Benefit
and Maturity Benefit which were originally payable will be restored on such PART F
Revival. However, no interest shall be payable by Us on such restoration. GENERAL TERMS AND CONDITIONS
3.3. If a Lapsed Policy is not revived within the Revival Period, this Policy will 1. ELIGIBILITY
immediately and automatically terminate without value, on the expiry of the 1.1 The Policy has been written on a single life basis.
Revival Period. 1.2. The minimum age of the Life Insured on the Date of Commencement of
3.4. If a Policy under Reduced Paid Up Mode is not revived within the Revival Risk should be at least 91 (Ninety-One) days.
Period then, the Policy under Reduced Paid Up Mode cannot be revived and 1.3. The maximum Age of the Life Insured on the Date of Commencement of
will continue to be under Reduced Paid Up Mode for the remaining part of Risk cannot exceed 60 (Sixty) years.
the Policy Term. 1.4. The maximum Age of the Life Insured on the Maturity Date cannot exceed
3.5. For the avoidance of doubt, the Policy cannot be revived beyond the Policy 80 (eighty) years.
Term. 2. TAXES
3.6. In addition to the revival provisions stated above, You may also be eligible to 2.1. All Premiums are subject to applicable taxes, cesses, and levies, if any
avail of one or more of the following revival schemes to revive Your Policy which will entirely be borne by You and will always be paid by You along
3.6.1 Reduction in the Sum Assured: You may be eligible to revive Your with the payment of Premium. If any imposition (tax or otherwise) is levied
Policy by reducing the Sum Assured. Please contact Us for details on by any statutory or administrative body under the Policy, We reserve the
whether You are eligible for this revival scheme and, if so, the extent right to claim the same from You. Alternatively, We have the right to
to which the Sum Assured can be reduced, the total amount required deduct the amount from the benefits payable by Us under the Policy.
to be paid by You to revive the Policy and the applicable terms and 2.2. Tax benefits may be available as per the prevailing tax laws. Tax laws
conditions for utilizing this revival scheme; and the benefits arising thereunder are subject to change. You are advised
3.6.2 Change in the Premium Payment Term: You may be eligible to revive to seek an opinion of Your tax advisor in relation to the tax benefits and
Your Policy by changing the Premium Payment Term. Please contact liabilities applicable to You.
Us for details on whether You are eligible for this revival scheme and 3. CLAIM PROCEDURE
if so, the extent to which the Premium Payment Term can be changed, 3.1. For processing a claim request under this Policy, We will require all of
the total amount required to be paid by You to revive the Policy and the following documents:
the applicable terms and conditions for utilizing this revival scheme; 3.1.1. Death Claim documents:
3.6.3 Special Revival Schemes: We may also introduce special revival a) Claimant's statement in the prescribed form;
schemes from time to time which are available for a particular period. b) original Policy document;
Please contact Us for details on whether such revival scheme is c) a copy of police complaint/ first information report (in the
available and, if You are eligible for the same, the total amount case of death by accident or suicidal death of the Life Insured);
required to be paid by You to revive the Policy and the applicable d) a copy of duly certified post mortem report (in the case of
terms and conditions for utilizing such revival scheme. death by accident or suicidal death of the Life Insured);
3.7. We may, from time to time, at Our sole discretion, introduce new e) a copy of death certificate issued by the local/municipal
revival schemes or modify or terminate existing revival schemes. Please authority duly attested by the Claimant (only in the case of
contact Us for details on [1860 120 5577] or visit Our website death of the Life Insured);
www.maxlifeinsurance.com. f) a self-attested copy of identity proof of the Claimant including
4. PAYMENT OF BENEFITS Nominee(s) bearing their photographs and signatures (only in
4.1. The benefits under this Policy will be payable only on submission of the case of the death of the Life Insured);
satisfactory proof to Us. The benefits under this Policy will be payable to g) Bank details of Claimant;
You/the Claimant as the case may be. h) any other document or information required by Us for
4.2. Once the benefits under this Policy are paid to You/the Claimant as the case assessing and approving the claim request.
may be, the same will constitute a valid discharge of Our liability under this 3.1.2. Maturity claim documents:
Policy. a) NEFT Form (if not provided earlier)
5. TERMINATION OF POLICY b) a cancelled cheque or copy of passbook with pre-printed name
This Policy will terminate upon the happening of any of the following events: and bank account number, for payout through NEFT (if not
5.1. on the date on which We receive Freelook cancellation request; provided earlier)
5.2. the date of death of the Life Insured; c) a self-attested photo ID proof
5.3. on the expiry of the Revival Period, if the Lapsed Policy has not been revived; 3.2. A Claimant can download the claim request documents from Our website
5.4. on the date of payment of Surrender Value; www.maxlifeinsurance.com or can obtain the same from any of Our
5.5. upon the payment of the maturity benefit; branches or offices.
5.6. upon payment of dues as per suicide clause (Clause 6 of Part-F); or 3.3. Subject to provisions of Section 45 of the Insurance Act, 1938 as amended
5.7. if the loan and accumulated interest exceeds the Surrender Value payable in from time to time, We shall pay the benefits under this Policy subject to
accordance with Clause 2.6 of part D. Our satisfaction:
6. FREELOOK CANCELLATION 3.3.1. that the benefits have become payable as per the terms and
"Freelook" means a period of 15 days or 30 days (if the Policy is sourced through conditions of this Policy; and
distance marketing modes such as internet, SMS, tele marketing, interactive 3.3.2. of the bonafides and credentials of the Claimant.
electronic medium etc.) from the date of receipt of the Policy, to review the 3.4. Subject to Our sole discretion and satisfaction, in exceptional
terms and conditions of the Policy, where if You disagree to any of those terms circumstances such as on happening of a Force Majeure Event, We may
and conditions, You have the option to return the Policy stating the reasons for decide to waive all or any of the requirements set out in Clause 3.1 of Part F.
objection. Upon return, the Policy will terminate forthwith and all rights, benefits 4. DECLARATION OF THE CORRECT AGE
and interests under the Policy will cease immediately. You shall be entitled to Declaration of the correct Age and/ or gender of the Life Insured is important for
a refund of the Premium received by Us after deducting the proportionate risk Our underwriting process and calculation of Premiums payable under the Policy.
premium for the period of cover, charges of stamp duty paid and the expenses If the Age and/or gender declared in the Proposal Form is found to be incorrect
incurred by Us on medical examination of the Life Insured, if any. at any time during the Policy Term or at the time of claim, We may exercise
7. LAPSATION OF POLICY / FORFEITURE OF PREMIUMS PAID Our rights under Section 45 of the Insurance Act, 1938 as amended from time
If You discontinue the payment of Premium before paying Premiums for any of to time or revise the Premium with interest and/or applicable benefits payable
the first 2 (Two) Policy Years, the Policy will become a Lapsed Policy on the under the Policy in accordance with the Premium and benefits that would have
expiry of the Grace Period and no benefits under the Policy shall be payable and been payable, if the correct Age and/ or gender would have made the Life Insured
in such event the Premium(s) paid, shall be forfeited by Us. eligible to be covered under the Policy on the Date of Commencement of Risk.
5. FRAUD, MISREPRESENTATION AND FORFEITURE
Fraud, misrepresentation and forfeiture would be dealt with in accordance with
provisions of Section 45 of the Insurance Act, 1938 as amended from time to

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 time. [A leaflet containing the simplified version of the provisions of the above 1.2.1. the complainant may file a written complaint with full details of the
section is enclosed in Annexure - 1 for reference] complaint and the complainant's contact information to the following
6. SUICIDE EXCLUSION official for resolution:
Notwithstanding anything stated herein, if the Life Insured commits suicide, Grievance Redressal Officer,
whether minor/major, whether sane or insane, within 12 (Twelve) months from Max Life Insurance Company Limited
the Date of Commencement of Risk or from the date of Revival of this Policy, Plot No. 90A, Sector 18
as applicable, all risks and benefits under this Policy shall cease the Policy shall Gurugram, 122015, Haryana, India
terminate immediately and We shall only pay the following to the Claimant, Helpline No - 1860 120 5577 or (0124) 4219090
provided that the Policy is in force: Email - [email protected]
6.1. higher of the Surrender Value as on the date of death or the sum of Total 1.2.2. the complainant may approach the Grievance Cell of the IRDAI on
Premiums Paid, plus loadings for modal premiums and Underwriting Extra the following contact details:
Premium, if any, paid till the date of death, if the Policy has acquired a IRDAI Grievance Call Centre (IGCC)
Surrender Value; or Toll Free No:155255 or 1800 4254 732
6.2. Total Premiums Paid plus loadings for modal premiums and Underwriting Email ID: [email protected]
Extra Premium, if any, received by Us, if the Policy has not acquired a 1.2.3. the complainant can also register Your complaint online at
Surrender Value. http://www.igms.irdai.gov.in/
7. TRAVEL AND OCCUPATION 1.2.4. the complainant can also register Your complaint through fax/paper
There are no restrictions on travel or occupation under this Policy. by submitting Your complaint to:
8. NOMINATION Consumer Affairs Department
Nomination is allowed as per Section 39 of the Insurance Act, 1938 as amended Insurance Regulatory and Development Authority of India
from time to time. [A leaflet containing the simplified version of the provisions Sy No. 115/1, Financial District,
of the above section is enclosed in Annexure - 2 for reference] Nanakramguda,Gachibowli, Hyderabad - 500032
9. ASSIGNMENT Ph: (040) 20204000
Assignment is allowed as per Section 38 of the Insurance Act, 1938 as amended 1.3. If the complainant are not satisfied with the redressal or there is no response
from time to time. [A leaflet containing the simplified version of the provisions within a period of 1 (One) month or within 1 year after rejection of
of the above section is enclosed in Annexure - 3 for reference] complaint by Us, the complainant may approach Insurance Ombudsman
10. POLICY CURRENCY at the address mentioned in Annexure A, or on the IRDAI website
This Policy is denominated in Indian Rupees. Any benefit/claim payments under www.irdai.gov.in or on Council of Insurance Ombudsmen website at
the Policy will be made in Indian Rupees by Us or in any other currency in www.cioins.co.in, if the grievance pertains to:
accordance with the applicable guidelines issued by the Reserve Bank of India 1.3.1 delay in settlement of a claim beyond the time specified in
from time to time. the regulations, framed under the Insurance Regulatory and
11. ELECTRONIC TRANSACTIONS Development Authority of India Act, 1999;
You will comply with all the terms and conditions with respect to all transactions 1.3.2. any partial or total repudiation of a claim by Us;
effected by or through facilities for conducting remote transactions including 1.3.3. dispute over Premium paid or payable in terms of the Policy; or
the internet, world wide web, electronic data interchange, call center, tele-service 1.3.4. misrepresentation of Policy terms and conditions at any time in the
operations or by other means of telecommunication established by Us or on Our Policy document or Policy contract;
behalf, for and in respect of the Policy or services, which will constitute legally 1.3.5. legal construction of the Policy in so far as the dispute relate to claim;
binding and valid transactions when executed in adherence to and in compliance 1.3.6 Policy servicing by Us, Our agents or intermediaries;
with the terms and conditions for such facilities. 1.3.7. issuance of Policy, which is not in conformity with the Proposal Form
12. AMENDMENT submitted by You;
No amendments to the Policy will be effective, unless such amendments are 1.3.8. non issuance of any insurance document after receipt of the Premium.
expressly approved in writing by Us and/or by the IRDAI wherever applicable. 1.3.9 Any other matter resulting from non-observance of or non-adherence
13. REGULATORY AND JUDICIAL INTERVENTION to the provisions of any regulations made by the IRDAI with regard
If any competent regulatory body or judicial body imposes any condition on to protection of policyholders' interests or otherwise, or of any
the Policy for any reason, We are bound to follow the same which may include circulars, guidelines or instructions issued by the IRDAI or of the
suspension of all benefits and obligations under the Policy. terms and conditions of the Policy contract, in so far as they relate to
14. FORCE MAJEURE issues mentioned in this para 1.3 above.
The performance of the Policy may be wholly or partially suspended during the 1.4. As per Rule 14 of the Insurance Ombudsman Rules, 2017, a complaint to
continuance of such Force Majeure Event with approval of the IRDAI. We will the Insurance Ombudsman can be made only within a period of 1 (One)
resume Our obligations under the Policy after the Force Majeure Event ceases year after receipt of Our rejection of the representation or after receipt of
to exist. Our decision which is not to Your satisfaction or if We fail to furnish reply
15. COMMUNICATION AND NOTICES after expiry of a period of one month from the date of receipt of the written
15.1. All notices meant for Us should be in writing and delivered to Our address representation of the complainant, provided the complaint is not on the same
as mentioned in Part G or such other address as We may notify from time to matter, for which any proceedings before any court, or consumer forum or
time. You should mention the correct Policy number in all communications arbitrator is pending.
including communications with respect to Premium remittances made by
You.
15.2. All notices meant for You will be in writing and will be sent by Us
to Your address as shown in the Schedule or as communicated by You
and registered with Us. We may send You notices by post, courier,
hand delivery, fax or e-mail/electronic mode or by any other means as
determined by Us. If You change Your address, or if the address of the
Nominee changes, You must notify Us immediately. Failure in timely
notification of change of address could result in a delay in processing of
benefits payable under the Policy.
15.3. For any updates, please visit Our website www.maxlifeinsurance.com.
16. GOVERNING LAW AND JURISDICTION
The Policy will be governed by and enforced in accordance with the laws of
India. The competent courts in India will have exclusive jurisdiction in all matters
and causes arising out of the Policy.
17. ISSUANCE OF DUPLICATE POLICY
You may request for a duplicate copy of the Policy to Us along with relevant
documents. Additional charges, not exceeding Rs.250/- may be applicable for
issuance of the duplicate Policy.

PART G
GRIEVANCE REDRESSAL MECHANISM AND OMBUDSMAN DETAILS
1. DISPUTE REDRESSAL PROCESS UNDER THE POLICY
1.1. All consumer grievances and/or queries may be first addressed to Your
agent or Our customer helpdesk as mentioned below:
a. Max Life Insurance Company Limited, Plot No. 90A, Sector 18,
Gurugram, 122015, Haryana, India, Helpline No.- 1860 120 5577 or
(0124) 4219090, Email: [email protected], Or
b. Any office of Max Life Insurance Company Limited.
1.2 . If Our response is not satisfactory or there is no response within 15 (Fifteen)
days:

11 of 29
ENDORSEMENT

STAMP DUTY AMOUNT : `1100.2

Paid by e-Stamps Certificate no. 1032/Issue Date: 30-09-2022/Vide Treasury

(E-CHALLAN) GRN NO.94778319 for Rs. 50000000

R Krishnakumar
Authorized Signatory

12 of 29
 Annexure 1 15.The provisions of sub-section 7 and 8 (13 and 14 above) shall apply to all life
Section 45 - Policy shall not be called in question on the ground of mis-statement insurance policies maturing for payment after the commencement of Insurance Laws
after three years (Amendment) Act 2015.16.If policyholder dies after maturity but the proceeds and
Provisions regarding policy not being called into question in terms of Section 45 of the benefit of the policy has not been paid to him because of his death, his nominee(s) shall
Insurance Act, 1938, as amended from time to time are as follows: 1.No Policy of Life be entitled to the proceeds and benefit of the policy.17.The provisions of Section 39
Insurance shall be called in question on any ground whatsoever after expiry of 3 yrs are not applicable to any life insurance policy to which Section 6 of Married Women's
from a. the date of issuance of policy or b. the date of commencement of risk or c.the Property Act, 1874 applies or has at any time applied except where before or after
date of revival of policy or d. the date of rider to the policy, whichever is later. 2.On the Insurance Act, 1938 as amended from time to time, a nomination is made in favour
ground of fraud, a policy of Life Insurance may be called in question within 3 years of spouse or children or spouse and children whether or not on the face of the policy
from a.the date of issuance of policy or b.the date of commencement of risk or c.the it is mentioned that it is made under Section 39. Where nomination is intended to be
date of revival of policy or d. the date of rider to the policy, whichever is later. For this, made to spouse or children or spouse and children under Section 6 of MWP Act, it
the insurer should communicate in writing to the insured or legal representative or should be specifically mentioned on the policy. In such a case only, the provisions
nominee or assignees of insured, as applicable, mentioning the ground and materials of Section 39 will not apply.
on which such decision is based. 3. 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 [Disclaimer: This is only a simplified version prepared for general information.
insurer to issue a life insurance policy: a.The suggestion, as a fact of that which is You are advised to refer to the Insurance Act 1938 as amended from time to time
not true and which the insured does not believe to be true;b. The active concealment for complete and accurate details.]
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 Annexure 3
fraudulent. 4.Mere silence is not fraud unless, depending on circumstances of the Section 38 - Assignment and Transfer of Insurance Policies
case, it is the duty of the insured or his agent keeping silence to speak or silence is Assignment or transfer of a policy should be in accordance with Section 38 of
in itself equivalent to speak. 5. No Insurer shall repudiate a life insurance policy on the Insurance Act, 1938 as amended from time to time. The extant provisions in
the ground of fraud, if the insured / beneficiary can prove that the misstatement was this regard are as follows:1.This policy may be transferred/assigned, wholly or in
true to the best of his knowledge and there was no deliberate intention to suppress part, with or without consideration.2.An Assignment may be effected in a policy
the fact or that such mis-statement of or suppression of material fact are within the by an endorsement upon the policy itself or by a separate instrument under notice
knowledge of the insurer. Onus of disproving is upon the policyholder, if alive, or to the Insurer.3. The instrument of assignment should indicate the fact of transfer
beneficiaries. 6.Life insurance Policy can be called in question within 3 years on the or assignment and the reasons for the assignment or transfer, antecedents of the
ground that any statement of or suppression of a fact material to expectancy of life assignee and terms on which assignment is made.4.The assignment must be signed
of the insured was incorrectly made in the proposal or other document basis which by the transferor or assignor or duly authorized agent and attested by at least one
policy was issued or revived or rider issued. For this, the insurer should communicate witness.5.The transfer or assignment shall not be operative as against an insurer until
in writing to the insured or legal representative or nominee or assignees of insured, as a notice in writing of the transfer or assignment and either the said endorsement
applicable, mentioning the ground and materials on which decision to repudiate the or instrument itself or copy there of certified to be correct by both transferor and
policy of life insurance is based.7.In case repudiation is on ground of mis-statement transferee or their duly authorised agents have been delivered to the insurer.6.Fee
and not on fraud, the premium collected on policy till the date of repudiation shall be to be paid for assignment or transfer can be specified by the Authority through
paid to the insured or legal representative or nominee or assignees of insured, within a Regulations.7.On receipt of notice with fee, the insurer should Grant a written
period of 90 days from the date of repudiation.8.Fact shall not be considered material acknowledgement of receipt of notice. Such notice shall be conclusive evidence
unless it has a direct bearing on the risk undertaken by the insurer. The onus is on against the insurer of duly receiving the notice.8.If the insurer maintains one or
insurer to show that if the insurer had been aware of the said fact, no life insurance more places of business, such notices shall be delivered only at the place where
policy would have been issued to the insured.9.The insurer can call for proof of age at the policy is being serviced.9.The insurer may accept or decline to act upon any
any time if he is entitled to do so and no policy shall be deemed to be called in question transfer or assignment or endorsement, if it has sufficient reasons to believe that it
merely because the terms of the policy are adjusted on subsequent proof of age of is a.not bonafide;b.not in the interest of the policyholder;c.not in public interest; or
life insured. So, this Section will not be applicable for questioning age or adjustment d.is for the purpose of trading of the insurance policy.10.Before refusing to act upon
based on proof of age submitted subsequently. endorsement, the insurer should record the reasons in writing and communicate the
same in writing to policyholder within 30 days from the date of policyholder giving
[Disclaimer: This is only a simplified version prepared for general information. a notice of transfer or assignment.11.In case of refusal to act upon the endorsement
You are advised to refer to the Insurance Act 1938 as amended from time to time by the insurer, any person aggrieved by the refusal may prefer a claim to IRDAI
for complete and accurate details.] within 30 days of receipt of the refusal letter from the insurer.12.The priority of
claims of persons interested in an insurance policy would depend on the date on
Annexure 2 which the notices of assignment or transfer is delivered to the insurer; where there
Section 39 - Nomination by Policyholder are more than one instruments of transfer or assignment, the priority will depend on
Nomination of a life insurance policy is as below in accordance with Section 39 of dates of delivery of such notices. Any dispute in this regard as to priority should
the Insurance Act, 1938 as amended from time to time. The extant provisions in this be referred to the Authority.13.Every assignment or transfer shall be deemed to be
regard are as follows:1.The policyholder of a life insurance policy on his own life may absolute assignment or transfer and the assignee or transferee shall be deemed to be
nominate a person or persons to whom money secured by the policy shall be paid in absolute assignee or transferee, except a.where assignment or transfer is subject to
the event of his death.2.Where the nominee is a minor, the policyholder may appoint terms and conditions of transfer or assignment OR b.where the transfer or assignment
any person to receive the money secured by the policy in the event of policyholder's is made upon condition that i.the proceeds under the policy shall become payable
death during the minority of the nominee. The manner of appointment is to be laid to policyholder or nominee(s) in the event of assignee or transferee dying before
down by the insurer. 3.Nomination can be made at any time before the maturity of the insured; or ii.the insured surviving the term of the policy.Such conditional
the policy. 4.Nomination may be incorporated in the text of the policy itself or may assignee will not be entitled to obtain a loan on policy or surrender the policy. This
be endorsed on the policy communicated to the insurer and can be registered by the provision will prevail notwithstanding any law or custom having force of law which is
insurer in the records relating to the policy.5.Nomination can be cancelled or changed contrary to the above position.14.In other cases, the insurer shall, subject to terms and
at any time before policy matures, by an endorsement or a further endorsement or a conditions of assignment, recognize the transferee or assignee named in the notice as
will as the case may be. 6.A notice in writing of change or cancellation of nomination the absolute transferee or assignee and such persona shall be subject to all liabilities
must be delivered to the insurer for the insurer to be liable to such nominee. Otherwise, and equities to which the transferor or assignor was subject to at the date of transfer
insurer will not be liable if a bonafide payment is made to the person named in or assignment;b.may institute any proceedings in relation to the policy; and c.obtain
the text of the policy or in the registered records of the insurer.7.Fee to be paid to loan under the policy or surrender the policy without obtaining the consent of the
the insurer for registering change or cancellation of a nomination can be specified transferor or assignor or making him a party to the proceedings 15.Any rights and
by the Authority through Regulations.8.On receipt of notice with fee, the insurer remedies of an assignee or transferee of a life insurance policy under an assignment
should grant a written acknowledgement to the policyholder of having registered a or transfer effected before commencement of the Insurance Laws (Amendment) Act,
nomination or cancellation or change thereof. 9.A transfer or assignment made in 2015 shall not be affected by this section.
accordance with Section 38 shall automatically cancel the nomination except in case
of assignment to the insurer or other transferee or assignee for purpose of loan or [Disclaimer: This is only a simplified version prepared for general information.
against security or its reassignment after repayment. In such case, the nomination will You are advised to refer to the Insurance Act, 1938 as amended from time to
get affected to the extent of insurer's or transferee's or assignee's interest in the policy. time for complete and accurate details.
The nomination will get revived on repayment of the loan.10.The right of any creditor
to be paid out of the proceeds of any policy of life insurance shall not be affected
by the nomination.11.In case of nomination by policyholder whose life is insured, if
the nominees die before the policyholder, the proceeds are payable to policyholder
or his heirs or legal representatives or holder of succession certificate.12.In case
nominee(s) survive the person whose life is insured, the amount secured by the policy
shall be paid to such survivor(s). 13.Where the policyholder whose life is insured
nominates hi a.parents or b.spouse or c.children or d.spouse and children e.or any of
them, the nominees are beneficially entitled to the amount payable by the insurer to
the policyholder unless it is proved that policyholder could not have conferred such
beneficial title on the nominee having regard to the nature of his title.14. If nominee(s)
die after the policyholder but before his share of the amount secured under the policy
is paid, the share of the expired nominee(s) shall be payable to the heirs or legal
representative of the nominee or holder of succession certificate of such nominee(s).

13 of 29
Annexure A: List of Insurance Ombudsman

AHMEDABAD - Office of the Insurance Ombudsman, 6th Floor, Jeevan Prakash Bldg, Tilak Marg, Relief Road,Ahmedabad-380
001. Tel.:- 079-25501201/02/05/06 Email: [email protected] (State of Gujarat and Union Territories of Dadra & Nagar Haveli and Daman
and Diu.)
BENGALURU - Office of the Insurance Ombudsman, Jeevan Soudha Bldg. ,PID No. 57-27-N-19, Ground Floor 19/19, 24th Main Road, JP Nagar, Ist Phase,
Bengaluru - 560 078. Tel.:- 080-26652049/26652048 Email: [email protected] (State of Karnataka)
BHOPAL - Office of the Insurance Ombudsman, 2nd Floor, Janak Vihar Complex, 6, Malviya Nagar, Opp. Airtel Office, Near New Market, Bhopal(M.P.)-462
003. Tel.: 0755 - 2769201 / 2769202 Email: [email protected] (States of Madhya Pradesh and Chhattisgarh)
BHUBANESHWAR - Office of the Insurance Ombudsman, 62, Forest park, Bhubneshwar - 751 009. Tel.: 0674 - 2596461 /2596455 Email:
[email protected] (State of Orissa).
CHANDIGARH - Office of the Insurance Ombudsman, S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building, Sector 17 - D, Chandigarh- 160 017. Tel.:
0172 - 2706468 / 2706196 Email: [email protected] [States of Punjab, Haryana (excluding 4 districts viz, Gurugram, Faridabad, Sonepat
and Bahadurgarh) Himachal Pradesh, Union Territories of Jammu & Kashmir, Ladakh and Chandigarh]
CHENNAI - Office of the Insurance Ombudsman, Fatima Akhtar Court, 4th Floor, 453, Anna Salai, Teynampet, Chennai - 600 018. Tel.: 044
- 24333668/ 24335284 Email: [email protected] (State of Tamil Nadu, and Union Territories - Puducherry Town and Karaikal (which are part
of Union Territory of Pondicherry)).
DELHI - Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building., Asaf Ali Road, New Delhi-110 002. Tel.:- 011-23232481/23213504 Email:
[email protected] (State of Delhi, 4 districts of Haryana viz, Gurugram, Faridabad, Sonepat and Bahadurgarh)
ERNAKULAM - Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam - 682015. Tel.: 0484 - 2358759
/ 2359338 Email: [email protected] (States of Kerala and Union Territory of (a) Lakshadweep (b) Mahe - a part of Union Territory of
Puducherry)
GUWAHATI - Office of the Insurance Ombudsman, "Jeevan Nivesh", 5th Floor, Nr. Panbazar over bridge, S.S. Road, Guwahati-781
001(ASSAM) Tel.:- 0361-2632204/2602205 Email: [email protected] (States of Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh,
Nagaland and Tripura.)
HYDERABAD - Office of the Insurance Ombudsman, 6-2-46, 1st Floor, Moin Court, Lane Opp. Saleem Function Palace, A.C. Guards, Lakdi-Ka-Pool,
Hyderabad-500 004. Tel.: 040 - 23312122 Email: [email protected] (State of Andhra Pradesh, Telangana and Yanam and part of the Union
Territory of Pondicherry.)
JAIPUR - Office of the Insurance Ombudsman, Ground Floor, Jeevan Nidhi II Bldg, Bhawani Singh Marg, Jaipur - 302005 Tel.: 0141 - 2740363 Email:
[email protected] (State of Rajasthan)
KOLKATA - Office of the Insurance Ombudsman, Hindustan Building. Annexe, 7th Floor, 4, C.R. Avenue, Kolkata-700 072. Tel :
033-22124339/22124340 Email: [email protected] (States of West Bengal, Sikkim, and Union Territories of Andaman & Nicobar Islands)
LUCKNOW - Office of the Insurance Ombudsman, 6th Floor, Jeevan Bhawan, Phase-2, Nawal Kishore Road, Hazaratganj, Lucknow-226 001. Tel : 0522
-2231331/2231330 Email: [email protected] (Following Districts of Uttar Pradesh: Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot,
Allahabad, Mirzapur, Sonbhadra, 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 - Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S.V. Road, Santacruz(W), Mumbai - 400054. Tel :
022- 69038821/23/24/25/26/27/28/29/30/31 Email: [email protected] (State of Goa and Mumbai Metropolitan Region excluding areas of Navi
Mumbai and Thane)
NOIDA - Office of the Insurance Ombudsman, 4th Floor, Bhagwan Sahai Palace,Main Road, Naya Bans, Sector-15, Distt: Gautam Buddh Nagar, U.P.
- 201301. Tel : 0120-2514252/2514253 Email: [email protected] (State of Uttaranchal and the following Districts of Uttar Pradesh:Agra, Aligarh,
Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar, 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.)
PATNA - Office of the Insurance Ombudsman, 2nd floor, North Wing, Lalit bhawan, Bailey Road, Patna - 800001 Tel : 0612-2547068 Email:
[email protected] (State of Bihar, Jharkhand.)
PUNE - Office of the Insurance Ombudsman,3rd Floor, Jeevan Darshan Bldg, C.T.S. No.s. 195 to 198, N.C. Kelkar Road, Narayan peth, Pune - 411030 Tel :
020-41312555 Email: [email protected] (State of Maharashtra including Navi Mumbai and Thane and excluding Mumbai Metropolitan Region.)

14 of 29
 MAX LIFE INSURANCE COMPANY LIMITED
Regd. Office : 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur,
District Nawanshahr, Punjab- 144533
Head Office: 11th & 12th Floor, DLF Square, Jacaranda Marg, DLF City
Phase-II, Gurugram Haryana, 122002.

PROPOSAL NUMBER:
NON LINKED PROPOSAL FORM
116319534
Combo Proposal Number: N/A GO/CA/Broker Code: X159 Customer ID: 159004843
For Traditional Insurance Plans this proposal is solicited by Axis Bank a Corporate Agent of
Max Life Insurance Co. Ltd.
Do you have Max Life Insurance Policy or have currently applied for simultaneous policies? If yes give policy/proposal number? YES-(828178061)

Purpose of Insurance: WEALTH ACCUMULATION/INVESTMENT

Objective of Insurance: INDIVIDUAL POLICY
Product Solution: N/A Affinity Customer: N/A Existing Customer: YES

A. Personal Details
Proposer/Joint Life Life to be Insured(if other than proposer)
1. Title MR MS

First K VISHNUPRIYA

2. Name Middle SASIDHARAN

Last ADIYODI SASIDHARAN

First RAGHAVAN
SASIDHARAN
3. Father's / Husband
Name
ADIYODI KENOTH
Last NAMBIAR

4. Date of Birth 11-04-1964 16-11-2001

5. Gender MALE FEMALE
6. Nationality NRI INDIAN
6a. Residence for Tax purposes in
UNITED ARAB EMIRATES
Jurisdiction(s) outside India
7. Marital Status MARRIED SINGLE
8. Education GRADUATE GRADUATE
9. Relationship with Proposer/ Joint Life NA DAUGHTER

10. Industry Type OTHERS OTHERS

11. Organisation Type PVT LTD NOT APPLICABLE

12. Occupation/Job Title SALARIED STUDENT
13. Name of Entity / Employer DRAGON OIL NA
14. Annual Income(Rs.) 7000000 300000

15. Is the Life to be Insured / Proposer / Joint Life / Nominee / Payor a Politically Exposed Person ? : NO

16. Nominee Details NA

17. Current Residential Address

House No./Apt. Name: SAIF RASHID AL HURAIZ BLDG

Society Road/Area/Sector: WATER SUB METER (FLAT 312) 318 47 AL KARAMA STREET DM 79

Landmark: PREMISE NUMBER 318131900 PREMISE TYPE RESIDENTAL FLAT

Village/Town:

City/District: DUBAI

Pin Code: 34666 State/UT: DUBAI Country: UAE

Mobile STD
Mobile No. 1: 1501400175 9895093465 Landline:
No. 2: Code:
Email: [email protected]

18. Permanent Residential Address (Optional)

Page 1 of 5 15 of 29
 House No./Apt. Name: HOUSE/BLDG/APT SOUPARNIKA,
Society Road/Area/Sector: STREET/ROAD/LANE GOPAL STREET,
Landmark:
Village/Town:
City/District: KANNUR
Pin Code: 670001 State/UT: KERALA Country: INDIA

19. Preferred Mailing Address. Current Residential

20. Do you wish to hold for this policy electronically under e-Insurance ? NO

B. Coverage Information-Type of Coverage

Premium Sum Income Premium Modal

Coverage
a. Base Plan Variant Back Assured/Annual Payout Payment Premium
Term
Option Income Payout Frequency Term (Rs.)
LUMP
MAX LIFE SMART WEALTH PLAN NA 4400000 ANNUAL 12 8 500000
SUM

Modal Premium without

GST* and Applicable Cess: 0 Total Premium Paid: 500000
GST* and Cess: 500000.0
(*GST shall comprise of CGST, SGST/UTGST or IGST (whichever is applicable) including cesses and levies, if any. All applicable taxes, cesses and levies, as per
prevailing laws, shall be borne by you)
c. Policy Continuance Benefit (PCB): NA
d. Bonus Option: NA
(Not Applicable for plans that offer reversionary Bonus)

2. NEFT Bank A/C Details of Proposer/ Joint Life: All Payouts will be credited to this account through Electronic mode of payment. (This will be applicable at
select cities as per facilities/arrangements of Max Life Insurance).
MICR Code: 670211002 Bank Account Number: 159010100040008
IFSC Code: UTIB0000159 Account Holder's Name: K
Type of Bank Account: NRE Bank Name & Branch: AXIS BANK KANNUR
Banking Since: 01-04-2005

3. Permanent Account
Number (PAN): Form 60 NO (for proposer/jointlife) Form 60 NA (for Insured)
ABTPA7408E
TDS may be applicable, in accordance with Income Tax Act 1961, as amended from time to time.
4. Mode of Payment:
5. Renewal premium by: DIRECT DEBIT 6. Source of Funds SALARY
ANNUAL
7. IS PAYOR DIFFERENT FROM THE PROPOSER ? NO

8. Are you a Max Life Agent or an employee of a Max group company/ Corporate Agents? NO
9. Effective Date of Coverage: 21-10-2022 05:30:00

10. Premium Payment Details

Amount in Words: FIVE LAKH
Paid Rs: 500000.0 Payment by DIRECT DEBIT
Cheque / Draft No. / Instrument no MAXCRM211159251022092200 Date: 25-10-2022
Bank Name & Branch:

C. INFORMATION OF LIFE TO BE INSURED

Proposer/Joint Life to be
Life Insured

1. Do you have any life or Critical Illness insurance policy issued, pending approval from any other insurance companies or has
your application for Life/Health/Critical illness insurance or its reinstatement ever been offered at modified terms,rejected or NO NO
postponed ?

Proposer/Joint Life to be
Life Insured

2. In the next 12 months do you intend to travel or reside abroad other than on holiday of less than 4 weeks? NA NO

3. Do you participate or do you intend to participate in any hazardous activities as part of your Occupation/ Sports/ Hobby? NA NO

4. Have you ever been convicted or are you under investigation for any criminal charges ? NA NO

5. For Female Life To Be Insured YES

Life to be
Proposer
Insured

Page 2 of 5 16 of 29
 a. Spouse Occupation NA NA

b. Spouse Annual Income NA NA

c. Spouse Insurance Amount NA NA

e. Full Name Prior to Marriage (If there is a name change post marriage): NA NA

f. Are you pregnant? NA NO

6. For Minor Life To Be Insured (Age < 18 yrs.) NO

D. Medical Information

Proposer/Joint Life to be
1. FAMILY HISTORY
Life Insured

Has any two (2) or more of your family members (parents & Siblings) ever been diagnosed with diabetes or
NA NA
hypertension or kidney failure or cancer or heart Attack or any Hereditory Disorder before the age of 60 ?

2.

Proposer/Joint Life Life To Be Insured

Height NA 157 cm
Weight NA 58 kg

Proposer/Joint Life to be
3. Have you ever been investigated, treated or diagnosed with any of the following conditions.
Life Insured

i) Diabetes /High blood sugar levels NA NO

ii) Hypertension/ High Blood Pressure, High Cholesterol or Thyroid disorder NA NO

iii) Heart or vascular disorder including chest pain, stroke, heart attack or Angioplasty, CABG or any other heart surgery. NA NO

iv) Breathing or lung disorders including asthma, emphysema, tuberculosis. NA NO

v) Liver or digestive system related disorder including jaundice ,gall bladder, pancreas or Hepatitis B/C. NA NO

vi) Any abnormal growth like tumour,lump,cancer or blood disorder, including anemia or thalassaemia or Sexually transmitted
NA NO
disease ( STD ) including HIV or AIDS.

vii) Any kind of Kidney or bladder disorder, including kidney failure, renal stone, nephritis or prostrate disorder. NA NO

viii) Any neurological or mental health problem like paralysis, multiple sclerosis, Parkinson's, epilepsy, depression or anxiety. NA NO

ix) Muscular-skeletal or joint disorders, including any kind of arthritis, gout, osteoporosis. NA NO

x) Are you having history of any hospitalization, treatment or investigation? NA NO

xi) Have you advised now or in last 5 yrs tests like X-Ray/CT scan/MRI/ Ultrasonography/ ECG/Blood test or any other
NA NO
investigatory or diagnostic tests, or any type of surgery.

Xii) Have you ever been diagnosed with any form of internal or external congenital anomaly or defect i.e. any condition(s) which is
NA NO
present since birth, and which is abnormal with reference to form, structure or position?

Xiii) Have you had any genetic testing before? NA NO

Proposer/Joint Life to be
4. Tobacco/Alcohol/Drugs Consumption: Do you consume any of the following ?
Life Insured

i) Tobacco ( Smoking /Chewing) currently or even occasionally in last 1 year ? NA NO

ii) Alcohol (ML) - Beer/Wine/Hard Liquor. NA NO

iii) Are you taking drugs like Cannabis/Marijuana,Ecstacy,Heroin,LSD,Amphetamines or any other illegal drugs? NA NO

E. Declaration And Authorisation

1. DECLARATION BY PROPOSER/ JOINT LIFE

I/We hereby declare that I/We fully understand the meaning and scope of the Proposal form and the questions contained above and I am submitting the
completed proposal form of my/our own volition, and confirm that I/We have not been induced by anyone to make the Proposal. I/We have been explained the
nature of questions and the importance of disclosing all material information.

I/We further declare that all the statements and declarations herein shall be the basis of a contract between me/us and the Company and that I/We have made
complete, true and accurate disclosure of all the facts and circumstances and have not withheld any information that may be relevant to enable the Company to
make an informed decision about the acceptability of the Proposal. I agree that in case of any fraud or misstatement, action will be initiated as per Section 45 of
Insurance Act, 1938, as amended from time to time. I/We undertake to notify the Company, forthwith in writing, of any change in any of the statements made in
the Proposal subsequent to the signing of this proposal and before acceptance of risk and issuance of the Policy by the Company. The first and subsequent year
premium will be paid out of legally acquired source of income. I will provide information as and when required by the Company, acting on its own or under any
order or instruction received from Statutory Authorities, as regards to the sources of funds or utilizations or withdrawals. I agree that the Company may provide
any information related to me in respect of this proposal; as available to the Company at any time, to any Statutory Authority in relation to the any laws including
the laws governing prevention of money laundering, applicable in the country. To enable the Company to assess the risk under my/our proposal or for any other

Page 3 of 5 17 of 29
purpose in relation to the policy, l/we, my/our heirs, administrators or executors or assignees hereby authorize my past or present employer(s)/business
association/medical practitioners /other agencies or governmental and/or any regulatory bodies, insurance repositories, CERSAI/ UIDAI, reinsurers / hospitals or
diagnostic centres/ other insurance companies/ service providers to disclose and make available to the Company such details/records, as may be requested by
the Company. I understand that I have disclosed my personal information with Max life and I hereby provide consent to Max Life to share, store my information
with its authorized service providers for servicing this policy/proposal such as issuance, underwriting renewal and claims process with respect to this policy as per
the regulation applicable from time to time. I/We submit the mandate to credit My / Our account towards all payments against the above policy and agree and
understand that payouts would be processed through electronic mode of payment and will be affected at select cities as per facilities/ arrangements of Max Life
Insurance. I/We authorize Max Life to send all communications by E-mail, SMS or any other communication mode. I/We agree to receive regular reminders,
updates / alerts from Max life from time to time.

Date: 23-10-2022 21:48:24 Place: DUBAI

VERNACULAR /ILLITERATE DECLARATION

(Declaration to be made by a person unconnected with Max life Insurance Company Limited but whose identify can be easily
established.) I hereby declare that I have fully explained the contents of this proposal to the proposer/Life to be Insured in
language, as understood by him/her and that the left thumb impression/signature of the
proposer/Life to be Insured has been appended/affixed after fully understanding the contents thereof. I have truthfully recorded the
answers given by the Proposer/Life to be Insured.I have understood the content of the proposal form as explained to me in
language by the declarant, Mr./Ms. ,filling in the
proposal form and after the same, I am affixing my signature/thumb-impression.

Name of the Declarant: Address of the Declarant:

I have understood the content of the proposal form as explained

to me in language by the
declarant, Mr./Ms. ,
filling in the proposal form and after the same, I am affixing my
signature/thumb-impression.

Signature / Thumb Impression / Electronic Signature of Signature / Thumb Impression / Electronic Signature of
Declarant Proposer / Joint Life

2. DECLARATION BY PRINCIPAL OFFICER/AGENT ADVISOR/SPECIFIED PERSON

I MR. VAISHAKH M do declare and confirm that I have met and explained the Product features, benefits, premium paying
term, nature of the questions contained in this Proposal form and other relevant terms and conditions to the Proposer and the Life Insured. I have also explained
that the answers to the questions forms the basis of the contract of the Insurance between the Company and the Proposer / Life Insured, and if any untrue
statement is contained therein and / or any information that may be relevant to enable the Company make an informed decision, the Company shall have the
right to vary the benefits which may be payable and / or treat the policy voidable at the option of the Company subject to section 45 of the Insurance Act, 1938 as
amended from time to time. I confirm that to the best of my knowledge the Life Insured does not suffer from any physical or mental abnormality or handicap or
has / had been hospitalised, undergone any surgery or treatment, or he /she is involved in activities including any hazardous avocation or occupation or any other
information material for underwriting this proposal form, unless expressly stated in this Proposal. I also declare and represent to the Company that I am in full
compliance with the regulatory requirements applicable to agent / corporate agent / specified person / broker prescribed by the Insurance Act 1938, as amended
from time to time and any other regulation, circular, instruction issued by IRDAI from time to time. I confirm that I have verified the identity, current / permanent
residential address of the Proposer/Life Insured, the nature of his/her business and his / her financial status basis the Max Life AML moral hazard checklist.

Is this a Replacement Sale? If yes, I have adequately explained the consequences of replacement sale
NO
to the customer.

Relationship of Principal Officer/Agent Advisor/Specified Person with the

Name of Principal Officer/Agent Advisor/Specified Person
Proposer/ Joint Life/ Life Insured

Customer MR. VAISHAKH M

Signature / Thumb Impression / Electronic Signature of Proposer/ Joint

Signature / Thumb Impression / Electronic Signature of Sales Manager
Life :- 25-10-2022 09:14:03
911883
This system generated benefit Proposal form shall be treated as signed
Specified Person License Number:SP0069466232
by me.

Phone No. with STD Code:-0

Date:- 23-10-2022 Place:- DUBAI

We confirm that we have made joint efforts in soliciting the prospect and will be jointly responsible for performing the service related to the policy. We further
confirm that the objective of sharing the commission is not for qualifying for any contest and/or reward & recognition programs of the company.

(Applicable only if more than one Agent Advisors share the commission)

Name(s) of Principal Officer/AA/Spec Person Principal Officer/AA/Spec Person Code % Share

Mr. Vaishakh M 911883 100

Page 4 of 5 18 of 29
Important Notes: (1) Any payment/s including initial payment accompanying this proposal, cash or by bearer instrument must be made at any of the Company's
General Office only. (2) Crossed cheque or bank drafts must be made in favour of MAX LIFE INSURANCE COMPANY LIMITED ACCOUNT (Proposal No. as
above) maybe handed over to the Agent Advisor. (3} Receipt of the Completed Proposal and initial payment does not create any obligations upon the Company
to underwrite the risk. The Company shall not be liable until it has underwritten the risk and issued the Policy. If the Policy is sent by post it shall be deemed to
have been delivered to and received by you in the ordinary course within 3 (three) days of posting. We draw your attention to Section - 39, Section - 45 and
Section - 41 of the Insurance Act 1938 which reads as follows-

Section 39: In case nomination facility is availed, section 39 of the Insurance Act, 1938 as amended from time to time shall apply.

Section 45: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of issuance of policy,
from the date of the Commencement of Risk or Revival of the policy or the date of the rider to the policy, whichever is later. However, Insurer may question the
Policy at any time within three years from the date of issuance of policy, from the date of Commencement of Risk or Revival of the policy or the date of the rider
to the policy, whichever is later, on the ground of fraud, in which case insurer shall inform Proposer/Life to be Insured/legal representatives in writing specifying
the grounds and materials on which such decision is based. For other details please referto Section 45 of the Insurance Act, 1938 as amended from time to time.

Section 41: (1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on
the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the
published prospectuses or tables of the insurer. (2) Any person making default in complying with the provisions of this section shall be punishable with fine which
may extend to ten lakhs rupees.

TRAD/mPro/AXIS/1021_5.7

Additional Declaration:

I hereby authorize AXIS BANK to share my last 6 months bank statement/ One Glance Statement (which includes savings, investments and liabilities in
Savings account, Current account, Deposits, Overdraft account, Demat Accounts, Investments, Insurance, Credit Cards etc. or other similar document and
personal KYC details/documents with Max Life for the purpose of insurance and confirm that the said details can be substantiated with adequate proofs as and
when required.

I / we understand that this is not a Fixed Deposit but a life insurance plan. I confirm that this proposal for insurance has being solicited independently and not
as consideration for any other service provided by AXIS BANK.

I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately

I am submitting my Electronic Application of my own volition and have understood the contents of the Electronic Application, and the relevant sales literature
including product features, benefits, applicable charges and am aware of the investment risk under the Policy.

I / We are aware that suitability information has been collected from me/us and recommendation on purchase of life insurance product has been made only
basis such information and any product selected by me/us that differs from such recommendation is on the basis of my/our personal choice. I / we have seen
and understood the benefit illustration shown to me / us on the screen electronically or provided to me / us in physical form, as the case may be. I / we have
disclosed all material information and not withheld any information that may be relevant to enable Max Life to take an informed decision about the acceptability
of the Electronic Application. I also confirm that the information in the Electronic Application, including the state of health and lifestyle habits of the life to be
insured is true and complete. I / we have submitted the confirmation number sent on my mobile number/ email id as a confirmation of the contents of the
Electronic Application and the benefit illustration and agreement to the terms therein.

I/We understand and agree that by submitting the Electronic Application, I / we will be bound by the statements / disclosures of material facts made therein in
the same manner, as if I / we have signed and submitted a written proposal for insurance to the Company and these shall be the basis of a contract between
me/us and the Company. I / we undertake to notify the Company of any change in statements made in the Electronic Application subsequent to its submission
and before acceptance of risk and issuance of the policy by the Company. I / we understand that in case the Company detects any fraud or mis-statement or
suppression of fact material to my/our life expectancy, the Company reserves the right to take appropriate action in accordance with Section 45 of the
Insurance Act.

I / we hereby declare and confirm that details provided in Form 60 attached to this Electronic Application (wherever applicable) are true and correct to the best
of my knowledge and belief. I declare that I do not have a Permanent Account Number and my/ our estimated total income (including income of spouse, minor
child etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which the
above transaction is held will be less than maximum amount not chargeable to tax.

I / we understand that the Company will not be liable unless the premium is received and realized by it within the time period stipulated for the same subject to
underwriting by it. I / we hereby authorize the Company to conduct screening / confirmation of my / our health status through medical examinations on the
basis of which, the Company may accept, decline or offer alternate terms on my proposal. I/we hereby authorize my past and present employer(s) /
associate(s) / medical practitioner(s) / any insurer or any other organization to disclose and make available to the Company my/our information.

I / We have filled the proposal electronically and have received the benefit illustration and filled up proposal form on email and registered mobile OR reviewed
it on tablet / desktop and after observing the said copy, I /we confirm that all the content / information therein is correct to the best of my / our knowledge.

I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately.

I do hereby certify that above stated information regarding the nationality and tax residential status is correct in all respects and may be used for all purposes,
including reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if any, to Max Life within 2 weeks of
occurrence of such change.

Signature / Thumb Impression / Electronic Signature of Sales Manager 911883

Signature / Thumb Impression / Electronic Signature of
Proposer/ Joint Life 23-10-2022 21:48:24
Specified Person License Number: SP0069466232

Phone No. with STD Code:0

Page 5 of 5 19 of 29
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 Pre Issuance Verification Confirmation

Date : 23-Oct-2022
Reference Number: 4003281035
Dear k
Subject: Confirmation of successful completion of Pre Issuance
Verification Process
Greetings from Max Life Insurance Company!
Thank you for completing Pre Issuance verification of your
application. We would like to assure you that your decision to take
the Life Insurance Policy with us is a prudent one.
This is with regards to the Policy Number: 116319534 where in you have
completed pre issuance verification process for further processing of your
application. Details are as follows:

Pre Issuance Verification Questions Your Responses

Do you understand that you have purchased a life insurance policy and
1 not a fixed deposit? You have not purchased this life insurance policy in Yes
exchange for Loan or other banking product.

According to the policy contract, you have agreed to pay Premium of

2 8
INR 500000 plus GST _____ every year/s

3 Are you aware that your policy will get matured after 12 years? Yes

Are you aware that you have chosen Lump Sum option and the
4 maturity benefit is a sum of Guaranteed Sum Assured on Maturity plus Yes
Accrued Guaranteed Additions?

Have you or any of your Family member(s) been tested for Covid-19 or
suffered from fever, cough, sore throat or Flu like symptoms in last 2
5 No
months or have you or your family members traveled overseas post 1st
Jan'20 or have any plans to travel Overseas in next 6 Months?

Are you working as a COVID warrior/ Health Care Worker (directly

6 involved in service COVID diagnosed people/ Doctors/ Nurses/ Allied No
health care professional

I hereby agree, declare and confirm that I have read and understood the benefit illustration, key feature
document (if applicable as per regulation) and the proposal form sent on my registered mobile number and
email. I have filled up the verification, health &habit questions and agree for it to be part of the proposal form. I
hereby confirm that all the content / information therein are true and correct to the best of my knowledge and
belief and has been collected from me and In person.

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We look forward to being your partner for life and are committed to provide you with the best of our
services.

Regards,
Max Life Insurance Co. Ltd.

Please note:
- This letter does not confirm issuance of the insurance policy. Issuance of Policy is subject to
realization of premium and completion of underwriting requirements.
- Please ensure that all the information provided by you including the medical facts are accurate as
per Pre Issuance Verification Process completed by you. If incase of non-disclosure or
misrepresentation, company has the right to reject the policy.
- Once the Policy is issued, you have a freelook period of 15 days from receipt of the insurance policy
to review its terms and conditions.

This email is electronically generated

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 BENEFIT ILLUSTRATION
[Date and Time of Illustration – 23 October 2022, 07:21 PM]

Name of the Prospect/Policyholder: Mr. K Proposal No: 116319534

Age & Gender: 58 Years, Male Name of the Product: Max Life Smart Wealth Plan
Name of the Life Assured: Ms. VISHNUPRIYA Tag Line: A Non-Linked Non Participating Individual Life Insurance Savings Plan
Age & Gender: 20 Years, Female Unique Identification No: 104N116V08
Policy Term: 12 Years GST Rate (Base Policy, First Year): 0.00%
Premium Payment Term: 8 Years GST Rate (Base Policy, Subsequent Year): 2.25%
Amount of Installment Premium: `5,00,000 GST Rate (Rider, First Year): NA
Mode of payment of premium: Annual
GST Rate (Rider, Subsequent Year): NA
Annual Income Amount: NA
Income Period, if applicable: NA Max Life State: Kerala
Mode of Income, if applicable: NA Policyholder Residential State: Dubai

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details
Policy Option Lump Sum Sum Assured (in Rs.) 44,00,000
Sum Assured on Death (at inception of the policy) (in Rs.) 55,00,000

Rider Details
Accidental Death & Dismemberment (ADD) Rider Premium
NA Accidental Death & Dismemberment (ADD) Rider Sum Assured (in Rs.) NA
Payment Term and Rider Term
Term Plus Rider Term NA Term Plus Rider Sum Assured (in Rs.) NA
Waiver of Premium (WOP) Plus Rider Term NA
Critical Illness and Disability Rider - Rider Premium Payment
NA Critical Illness and Disability Rider - Coverage Variant NA
Term and Rider Term
Critical Illness and Disability Rider - Rider Sum Assured NA

Premium Summary
Accidental Death & Waiver of Premium Plus Critical Illness and Total Installment Premium
Base Plan Dismemberment Rider
Term Plus Rider Rider Disability Rider
Installment Premium without GST (in Rs.) 5,00,000 0 0 0 0 5,00,000
Installment Premium with first year GST (in Rs.) 5,00,000 0 0 0 0 5,00,000
Installment Premium with GST 2nd year onwards (in Rs.) 5,11,250 0 0 0 0 5,11,250

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UIN: 104N116V08 Max Life Insurance Company Limited having its Corporate Office at 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurugram – 122002 Page 1 of 2
 (Amount in Rupees)

Guaranteed Non Guaranteed

Single/ Annualized
Policy Year Total Annual Premium Other Benefits, if any
Premium Accrued Guaranteed Min Guaranteed Special Surrender Value
(Guaranteed Sum Maturity Benefit Death Benefit
Additions Surrender Value
Assured at Maturity)
1 5,00,000 5,00,000 - - - 55,00,000 - -
2 5,00,000 5,00,000 - - - 55,00,000 3,00,000 4,20,000
3 5,00,000 5,00,000 - - - 55,00,000 5,25,000 7,35,000
4 5,00,000 5,00,000 - - - 55,00,000 10,00,000 14,00,000
5 5,00,000 5,00,000 - - - 55,00,000 12,50,000 17,50,000
6 5,00,000 5,00,000 - - - 55,00,000 15,00,000 22,29,900
7 5,00,000 5,00,000 - - - 55,00,000 17,50,000 27,77,250
8 5,00,000 5,00,000 - - - 57,43,600 24,00,000 33,88,400
9 - - 5,50,400 - - 62,03,200 29,65,120 38,92,400
10 - - 11,00,800 - - 66,99,600 35,30,240 46,31,760
11 - - 16,51,200 - - 72,35,600 40,95,360 56,07,680
12 - - 22,01,600 44,00,000 66,01,600 78,14,400 42,60,480 66,01,600

Notes:
• Annualized Premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and Goods and Service Tax.
• Total Annual Premium includes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any but excludes Goods and Service Tax.
• Refer Sales literature (Prospectus) for explanation of terms used in this illustration.

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

Place: Signature / Thumb Impression / Electronic Signature of Date:10/23/22 Signature / Thumb Impression / Electronic Signature of
Date: 10/23/22 Agent/ Intermediary / Official Prospect/ Policyholder
This system generated benefit illustration shall be treated as signed by me.

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UIN: 104N116V08 Max Life Insurance Company Limited having its Corporate Office at 11th Floor, DLF Square, Jacaranda Marg, DLF City, Phase II, Gurugram – 122002 Page 2 of 2
84,20,12,4400000,0,500000,F
 Premium Receipt
Receipt No.: 116319534NOV2201 | Receipt Date: 10-NOV-2022
Personal Details
Policy Number: 116319534 Email ID: [email protected]
Policyholder Name: Mr. K Sasidharan Adiyodi PAN Number: ABTPA7408E
Address: SAIF RASHID AL HURAIZ BLDG WATER SUB METER (FLAT 312) 318 47 AL KARAMA STREETCustomer GSTIN: Not Available
DM 79 Current Residential State: Foreign State
PREMISE NUMBER 318131900 PREMISE TYPE RESIDENTAL FLAT
Dubai- 34666
UAE United Arab Emirates
Mobile Number: 1501400175
Policy Details

Plan Name: Max Life Smart Wealth Plan Policy Commencement Date: 21-OCT-2022
Life Insured: Ms. Vishnupriya Sasidharan Policy Term: 12 Years Premium Payment Term: 8 Years
Premium Payment Frequency: Annual Date of Maturity: 21-OCT-2034 Modal Premium (incl. GST): ` 5,11,250.16
Late Payment Fee (incl GST): ` 0.00 Premium Received (incl. GST): ` 5,00,000.16
GST Details Connect for more details
Coverage Taxable SGST/UTGST CGST IGST Name
Type Value (`) Rate Amount (`) Rate Amount (`) Rate Amount (`) M/S. Axis Bank Ltd Kannur
Base 0.00 NA 0.00 NA 0.00 18% 0.00
Rider 0.00 NA 0.00 NA 0.00 18% 0.00
Contact Number
Late Payment 0.00 NA 0.00 NA 0.00 18% 0.00
1860 120 5577 or (0124) 4219090
Total GST Value: ` 0.00
GSTIN: 32AACCM3201E1ZC GST Regd. State: Kerala SAC CODE: 997132

Mudrank: Paid by e-Stamps Certificate no. 948/Issue Date: 4/04/2022/ Vide Treasury (E-CHALLAN) GRN NO.88821464

Minimum Guaranteed
Death Benefit (of base plan
and term rider (if any))
21-OCT-2022 to
` 55,00,001.76 ` 5,00,000.16 20-OCT-2023 21-OCT-2023
*Important Note:
1.For payment mode other than in cash, this receipt is conditional upon the credit in our account. Payment of premium amount does not constitute commencement of risk. The risk
commencement starts after acceptance of risk by us.
2.Amount received would be adjusted against the due premium as per terms and conditions of the policy.
3.Premiums may be eligible for tax benefits under section 80C/80CCC/80D/37(1) of the income Tax Act 1961. Kindly consult your tax advisor for more information. Tax benefits are liable
to change due to changes in legislation or government notification.
4.GST shall comprise CGST, SGST / UTGST or IGST (whichever is applicable) including cesses and levies, if any as per prevailing laws and shall be borne by you. For GST purposes, this premium
receipt is Tax invoice. Assessable Value in GST for Endowment First Year is 25%, Renewal Year is 12.5%, Single Premium Annuity is 10%, Term and Health is 100%. Currently base GST
rate is 18% apart from cess in some states.

Authorised Signatory
PRM20 PRODUCT UIN: 104N116V08
E.&O.E

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