Faidey ka Insurance

KOTAK PROPOSAL FORM

APPLICATION NO.:
KP (KPF) FORM ID NO: 10101630

NON UNIT LINKED UNIT LINKED: “IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.”
FOR OFFICE USE ONLY

Proposal Number Proposal Receipt Date D D M M Y Y Y Y

Agent ID Cross Reference No.
(Life Advisor/Corporate Agent/Broker/Relationship Officer)

Name of the Product Branch Code

Product Code Client ID (for new customers)

Opportunity ID
CATEGORY TO WHICH THE PROPOSER BELONGS:
A. Rural Urban
B. Unorganized Sector Economically Vulnerable / Backward Class Other Categories

INSTRUCTIONS FOR FILLING UP THE FORM

1. Please answer all questions. 2. Please tick a box thus R where appropriate. 3. Please strike out parts which are not applicable and write 'N.A.'. 4. Strokes of the pen, dots and dashes will not be
accepted as replies. 5. This form is to be filled by the proposer himself/herself in BLOCK LETTERS in black or blue ink. In case he/she is unable to do so, he/she may dictate the answers to the questions in
the proposal form to a scribe, other than the Company's Life Advisor / Corporate Agent / Broker / Relationship Officer. 6. The proposer must sign any cancellation or alteration.
7. Insurance is a contract of utmost good faith, which requires the proposer and life to be insured to disclose all material facts. In case of any doubt as to whether a fact is material or not, the fact should be
disclosed. As the statements in this proposal constitute warranties, complete and accurate information must be given. 8. Please use additional sheet where space is not sufficient.

1. PARTICULARS OF THE LIFE TO BE INSURED AND PROPOSER (to be filled in BLOCK LETTERS)
PROPOSER (to be filled only if different
PARTICULARS LIFE TO BE INSURED from the life to be insured)

1.1 CLIENT ID (for existing Kotak

Life Insurance policyholders)

1.2 TITLE Mr. Ms. Mrs. Master Mr. Ms. Mrs. Master
1.3 FULL Surname
NAME
First Name
Middle Name
1.4 MAIDEN Surname
NAME (in case
of married First Name
female)
Middle Name
1.5 FATHER's Surname
/ HUSBAND's
First Name
NAME
Middle Name
1.6 NATIONALITY Indian NRI/ PIO 1 Others (please specify) Indian NRI/PIO 1 Others (please specify)
1.7 GENDER Male Female Male Female
1.8 DATE OF BIRTH D D M M Y Y Y Y D D M M Y Y Y Y
1.9 GROSS ANNUAL INCOME (In Rs. per annum) (In Rs. per annum)
1.10 PROOF OF AGE Passport Birth Certificate School Leaving Cert. Passport Birth Certificate School Leaving Cert.
Driving Licence Others (please specify) Driving Licence Others (please specify)
1.11 MARITAL STATUS Single Married Divorced Widow(er) Single Married Divorced Widow(er)
1.12 EDUCATIONAL Professional Post-Graduate Graduate Professional Post-Graduate Graduate
QUALIFICATION (Tick Highest)
12th pass 10th pass Below 10th 12th pass 10th pass Below 10th
Others (please specify) Others (ple. specify)
1.13 OCCUPATION CATEGORY Salaried Self Employed Retired Salaried Self Employed Retired
Student Housewife Others (please specify) Student Housewife Others (ple. specify)
1.14 a) IF SALARIED Private Ltd. Public Ltd. Govt. Private Ltd. Public Ltd. Govt.
(please tell us the type of organization)
Trust Partner / Proprietor Others (please specify) Trust Partner / Proprietor Others (ple. specify)
1.14 b) IF SELF-EMPLOYED Trading Manufacturing Professional Trading Manufacturing Professional
(please tell us the type of organization)
Others (please specify) Others (please specify)
1.15 C/o or S/o or W/o
PERMANENT House/Flat No./Society
RESIDENTIAL
ADDRESS Street/Lane/Mohalla
Landmark
Area/Location
Village/Taluka/Tehsil
City/District
State Pin Pin
 APPLICATION NO.:
KP (to be filled only if different
PARTICULARS LIFE TO BE INSURED PROPOSER from the life to be insured)
1.16 C/o or S/o or W/o
CURRENT House/Flat No./Society
RESIDENTIAL
ADDRESS Street/Lane/Mohalla
(If different Landmark
from Area/Location
Permanent
Residential Village/Taluka/Tehsil
Address) City/District
State Pin Pin
1.17
OFFICE
ADDRESS
(company Street/Lane
name and Landmark
full address Area/Location
of present
employer)
City/District
State Pin Pin
1.18 PREFERRED MAILING ADDRESS Permanent Residential Current Residential Office Permanent Residential Current Residential Office
1.19 WORK DETAILS a) No. of Years in Service b) Designation c) Nature of Work a) No. of Years in Service b) Designation c) Nature of Work
(present employment)

d) Nature of Business of the Organization d) Nature of Business of the Organization

1.20 TELEPHONE NUMBER Residence Residence

(with STD Codes) Office Office
Mobile Mobile
1.21 E-mail ID
1.22 IT ASSESSEE Yes No Yes No
1.23 PERMANENT A/C NO. (PAN) Enclosed Yes No Enclosed Yes No
1.24 IF PAN NOT AVAILABLE Applied for Not Applied for Applied for Not Applied for
1.25 RELATIONSHIP TO LIFE TO BE
NOT APPLICABLE
INSURED
1.26 TOTAL EXISTING LIFE COVER
NOT APPLICABLE
(excluding this proposal) (in Rs.)

2. ADDITIONAL INFORMATION OF THE LIFE TO BE INSURED AND PROPOSER

(to be filled only if different
PARTICULARS LIFE TO BE INSURED PROPOSER from the life to be insured)

2.1 PROOF OF IDENTITY Passport Voter’s Identity Card Ration Card Passport Voter’s Identity Card Ration Card
PAN Card Driving Licence Others (ple. specify) PAN Card Driving Licence Others(ple. specify)
2.2 PROOF OF PERMANENT Telephone Bill Electricity Bill Passport Telephone Bill Electricity Bill Passport
RESIDENCE (in case both are different,
proof of Permanent Residence of Proposer only) Driving Licence Voter’s Identity Card Others (ple. specify) Driving Licence Voter’s Identity Card Others (ple. specify)
2.3 PROOF OF CURRENT Telephone Bill Electricity Bill Passport Telephone Bill Electricity Bill Passport
RESIDENCE (in case both are different,
proof of Current Residence of Proposer only) Driving Licence Voter’s Identity Card Others (ple. specify) Driving Licence Voter’s Identity Card Others(ple. specify)
2.4 SOURCE OF EARNINGS Salary Business Income Inheritance Salary Business Income Inheritance
Others (ple. specify) (ple. specify)
Others (please specify)
2.5 PROOF OF INCOME (where sum of IT Returns Employer’s Certificate Audited P/L Accts. IT Returns Employer’s Certificate Audited P/L Accts.
annualized premiums across all policies with KLI
[including at proposal stage] is Rs. 1 Lakh or more) Others (ple. specify) Others (ple. specify)
2.6 OTHER DETAILS LIFE TO BE INSURED PROPOSER
a) Do you have any history of conviction under any criminal proceedings in India or abroad? Yes No Yes No
b) Are you a Politically Exposed Person (these are the people who hold prominent public function viz. Heads/Ministers of Central or
State Govt, Senior Politicians, Senior Govt., Judicial or Military Officials, Senior Executives of Govt. companies, Important Political
Party Officials, and immediate family members of above persons)? Yes No Yes No
c) Is your occupation associated with any specific hazards which would render you susceptible to any injury or illness, e.g. chemical
factory, mines, explosives, corrosive chemicals, etc.? Yes No Yes No
d) Are you currently engaged in or intend to take part in any hazardous hobbies / activities which would increase the risk of any injury or
illness to you? Yes No Yes No
e) If your answer is 'Yes' to any of the above questions kindly give details:

3. PARTICULARS OF THE PLAN PROPOSED

3.1 NAME OF THE PLAN / RIDER POLICY TERM (Yrs.) SUM ASSURED (Rs.) MODAL PREMIUM (Rs.)
a) BASIC BENEFIT

b) OPTIONAL RIDER BENEFITS

(please fill the Life Guardian Addendum
where applicable)

POLICY FEES 2
TOTAL PREMIUM (ROUNDED OFF TO THE NEAREST RUPEE)
3.2Frequency of Premium Payment Single Yearly Half - Yearly Quarterly Monthly
3.3 Premium Payment Term (Years) Full Policy Term Others (please specify)
2
Policy Fees applicable as per terms and conditions mentioned in the policy document.
 APPLICATION NO.:
KP
4. DETAILS FOR UNIT LINKED PLANS ONLY
4A.1 For KOTAK HEADSTART PLANS, please choose the plan variant below (in case of Joint Life plans, please fill in the Joint Life Addendum)
Assure Wealth - Single Life Assure Wealth - Joint Life Future Protect - Single Life Future Protect - Joint Life

4A.2 For KOTAK HEADSTART FUTURE PROTECT (Joint Life option),

Please indicate the fund name for 100% allocation of 'Additional Death Benefit' on prior death of Primary Life Insured

4A.3 For KOTAK PLATINUM EDGE,

Please choose the option for Death Benefit Simple Protection Double Protection

4A.4 Please indicate your fund allocation below (please tick thus R
where appropriate) (Total must be equal to 100%) :

A Kotak Safe Investment Plan II

Guarantee Fund (%)
Money Market Fund (%)

B Kotak Single Invest Kotak Long Life Plans Kotak Headstart Plans Kotak Platinum Edge Kotak Super Advantage

Classic Opportunities Fund (%)

Frontline Equity Fund (%)
Balanced Fund (%)
Peak Guarantee Fund3 (%)
Dynamic Floor Fund II (%)
Bond Fund (%)
Gilt Fund (%)
Floating Rate Fund (%)
Money Market Fund (%)

3
This is a closed-ended fund and will be available for specific periods from time to time. Please consult your Life Advisor/Corporate Agent/Broker/Relationship Officer regarding its availability.
In Kotak Platinum Edge, this fund is available only with premium payment term of 3 years.

4B. DETAILS FOR NON-UNIT LINKED PLANS ONLY (Subject to acceptance of risk by insurer)
4B.1 For KOTAK CAPITAL MULTIPLIER PLAN, to withdraw the maturity proceeds, I would like to opt for a Kotak Mahindra Bank Account 4 Immediately At Maturity

4B.2 Do you want the policy to be backdated? Ye s No

(Should not precede 1st April
4B.3 If "Yes", specify backdation date D D M M Y Y Y Y and fill in corresponding age on Last Birthday (at that date)
of current Financial Year)
4B.4 If "No", then state, which date do you want the cover to commence from? (Tick any one box)
(Should not exceed 1 month from the
Date of Proposal Deposit Receipt Date of Issue of Policy Specified Future Date D D M M Y Y Y Y date of submission of proposal from)
4
Extending of this facility shall be at the sole discretion of Kotak Mahindra Bank Ltd (KBML) and shall be subject to the terms and conditions prescribed.

5. DETAILS OF PROPOSAL DEPOSIT PAID

5.1 MODE OF PAYMENT Cheque/DD Cash (Should you choose to pay premiums by cash, you are advised to do so at the nearest Kotak Life Insurance branch only)
5.2 CHEQUE / DD NO. 5.3 DATED 5.4 AMOUNT (in Rs.) 5.5 DRAWN ON (Name of Bank and Branch)

D D M M Y Y Y Y
5.6 IFSC CODE
6. BANK DETAILS FOR DIRECT CREDIT OF BENEFITS/REFUNDS
6.1 BANK NAME 6.2 BANK BRANCH 6.3 BANK CODE
6.4 ACCOUNT NUMBER 6.5 NEFT/RTG/IFSC CODE 6.6 MICR NO.
Note:The client undertakes the responsibility to intimate KLI regarding change in bank details. The claims arising under this policy will be settled through the above-mentioned Bank Account only.

7. PARTICULARS OF NOMINEE 5 / BENEFICIARIES 6

PARTICULARS NOMINEE / BENEFICIARY ADDITIONAL NOMINEE / BENEFICIARY

7.1 CLIENT ID (for existing Kotak Life
Insurance policy holder)

7.2 Percentage of Share % %

7.3TITLE Mr. Ms. Mrs. Master Mr. Ms. Mrs. Master
7.4 FULL Surname
NAME First Name
Middle Name
7.5 NATIONALITY Indian NRI / PIO 7 Others (Pls specify) Indian NRI / PIO 7 Others (Pls specify)
7.6 GENDER Male Female Male Female
7.7 DATE OF BIRTH D D M M Y Y Y Y D D M M Y Y Y Y

7.8 C/o or S/o or W/o

CURRENT House/Flat No./Society
RESIDENTIAL
ADDRESS Street/Lane
Landmark
Area/Location
Village/Taluka
City/District
State Pin Pin
7.9 RELATIONSHIP TO LIFE TO BE
INSURED
5 6
Applicable only if Proposer and Life to be Insured are the same. In case of more than 2 nominees, please fill in the Additional Nominee Form. Applicable for Kotak Headstart Plans. 7 Please fill in the NRI / PIO Questionnaire.
 APPLICATION NO.:
KP
8. PARTICULARS OF APPOINTEE 8 / LEGAL GUARDIAN 9

8.1 TITLE SURNAME FIRST NAME MIDDLE NAME

8.2 CLIENT ID(for existing 8.3 DATE OF BIRTH D D M M Y Y Y Y 8.4 RELATIONSHIP TO NOMINEE /
Kotak Life Insurance policy holder) BENEFICIARY
8.5 CURRENT RESIDENTIAL ADDRESS
Village/ District Land Mark
City State Pin

8.6 Signature/Thumb Impression of the Appointee

8 9
Where the Nominee(s) is/are a minor. For Kotak Headstart Plans only, where the beneficiary is a minor.

9. DETAILS OF LIFE INSURANCE POLICIES HELD / PROPOSALS APPLIED FOR BY THE LIFE TO BE INSURED
9.1 Do you have any existing life insurance policies with Kotak Life Insurance or other companies ? Yes No At the proposal stage
9.2 If 'Yes' or 'At the proposal stage', please give the following details :
Policy/ Company Name Sum Assured Acceptance Terms (Std./With In Force/Lapsed
Proposal (including Kotak On Death On Accidental On On Critical Extra / Postponed / (Mention year of Lapse/
No. Life Insurance) Death Disability Illness Declined / Not Completed) Revival applied for)

10. PERSONAL HEALTH DETAILS OF THE LIFE TO BE INSURED

10.1 HEIGHT cms OR feet inches

10.2A WEIGHT kgs 10.2B Have you Gained or Lost Weight (more than 5 kgs) in the last 1 year? Yes No

10.2C If Yes, then please specify "+" Kgs OR “-" Kgs Please specify the reason for this Gain/Loss (please specify)

10.3 LIFESTYLE DETAILS CURRENT USAGE PAST USAGE

Current If YES, form of Since When Average usage Past If YES, form of Past average Reasons for
Usage consumption per day Usage consumption usage per day giving up
Tobacco Cigarette/ Beedi/ Cigarette/ Beedi/ Doctor's Advice / Others
Yes No Chewing Tobacco/ Yes No Chewing Tobacco/
Tobacco Toothpaste Tobacco Toothpaste

Alcohol 10 Yes No Beer/ Wine/ Hard Liquor Yes No Beer/ Wine/ Hard Liquor Doctor's Advice / Others

Any Narcotics Counseling,

Yes No
(For medical/ recreational purposes) Yes No Rehabilitation etc
10
1 unit = half pint beer/1 glass of wine/1 measure of spirits.

Faidey ka Insurance

Application No.:
KP ACKNOWLEDGEMENT*

Agent ID (Life Advisor/Corporate Agent/ Date D D M M Y Y Y Y

Broker/Relationship Officer)

Received from Mr./Ms. the proposal for Life Insurance with Kotak Mahindra Old Mutual Life

Insurance Limited along with Rs. by way of Cheque**/DD** no.

Dated D D M M Y Y Y Y Drawn On Bank, Branch OR

by way of Cash Deposit Dated D D M M Y Y Y Y with Kotak Life Insurance Branch.

Date: D D M M Y Y Y Y Place:

NAME SIGNATURE
(Name and Signature of the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker / Relationship Officer)
* Please note that, this acknowledgement does not in any way constitute acceptance or commencement of risk.
** All cheques/demand draft should be crossed and drawn in favour of "KOTAK LIFE INSURANCE" OR "KOTAK MAHINDRA OLD MUTUAL LIFE INSURANCE LIMITED".
 APPLICATION NO.:
KP
11. FAMILY HISTORY OF THE LIFE TO BE INSURED
11.1 LIVING DECEASED LIVING DECEASED
AGE STATE OF HEALTH AGE AT DEATH CAUSE OF DEATH AGE STATE OF HEALTH AGE AT DEATH CAUSE OF DEATH
Father Children
Mother
Sister/
Spouse
Brother(s)
Children
11.2A Have your parents / brothers / sisters / spouse / children ever suffered from or died of heart disease, stroke, high blood pressure, diabetes mellitus, any form of eye disease, cancer,
kidney disease or paralysis, or any hereditary / familial disorders, tuberculosis, or any contagious diseases such as hepatitis, AIDS / HIV etc.? Yes No

11.2B If your answer is 'Yes' to the above question, kindly give details:

12. MEDICAL HISTORY OF THE LIFE TO BE INSURED (Not to be filled in case the 'Medical Addendum’ is being completed by the Life to be Insured)
12.1 Are you currently in good health and not suffering from any ailment, whether or not under treatment? Yes No

12.2 Have you ever suffered from or received treatment or advice for any of the following diseases or impairments:
(i) Cancer, tumour or growth, diabetes, disease of the heart, coronary, artery disease, blood circulatory system including high blood pressure,
raised cholestrol or stroke, chest pain, epilepsy, mental or nervous disorder including depression, kidney disease, liver disease including hepatitis,
respiratory disease, urinary or bowel disorder, or any other significant disease or impairment? Yes No

(ii) HIV infection, AIDS-related or any other sexually transmitted disease? Yes No

12.3 In the last 5 years, have you remained absent from work for five consecutive days or spent three consecutive days in hospital for any illness, sickness,
disease, injury or disorder? Please ignore normal pregnancy. Yes No
12.4 In the last 3 years, have you been treated, are currently undergoing or have been advised to treatment from a doctor or specialist or undergone any
cardiological, radiological or pathological tests (excluding routine check-ups)? Yes No
12.5 Are you currently receiving or considering receiving medical attention or taking any prescribed drugs? Yes No

12.6 For Female Lives only

(i) Are you currently pregnant? (If yes, please mention the month of pregnancy) month(s) Yes No

(ii) Have you ever suffered from or are currently suffering from any complications of pregnancy? Yes No

(iii) Have you ever suffered from or are currently suffering from any diseases of the breast / uterus / cervix? Yes No

12.7 If your answer is 'Yes' to any of the above questions (or 'No' in case of 11.1), kindly give details:

SECTION 41 OF THE INSURANCE ACT, 1938 (4 OF 1938): (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:Provided
that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium
within the meaning of this sub section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the
insurer.(2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees
SECTION 45 OF THE INSURANCE ACT, 1938 (4 OF 1938): No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of
commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall, after the expiry of two years from the date on which it was effected, be called in question
by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue
of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by
the policyholder and that the policyholder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose.
Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because
the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.

FOR YOUR REFERENCE

1. This is an acknowledgement by the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker /
Relationship Officer of having received the Proposal Form. This is not a receipt issued by Kotak Mahindra Old Mutual Life
Insurance Limited.
2. Kotak Mahindra Old Mutual Life Insurance Limited shall issue a proposal deposit receipt (PDR) on receiving the
completed proposal form with the cash / cheque / demand draft at its branch office.
3. In case of non-receipt of your PDR or for any clarification, kindly contact your Life Advisor/Specified person of Corporate
Agent/Authorised Employee of Broker / Relationship Officer.
4. For further assistance, do write to us at lifeexpert@kotak.com

Kotak Mahindra Old Mutual Life Insurance Ltd.

Regn. No. 107, Regd. Office: Kotak Mahindra Old Mutual Life Insurance Ltd., 9th Floor, Godrej Coliseum, Behind Everard Nagar, Sion (East), Mumbai - 400 022.
www.kotaklifeinsurance.com
Insurance is the subject matter of the solicitation.
PF01-0503-ENG/V1.6/PRN/150K/06/JAN/10/001/AL/1/HO
 13. DECLARATION BY THE LIFE TO BE INSURED, PROPOSER AND IN CASE OF MINOR BY HIS/HER LEGAL GUARDIAN
APPLICATION NO.:
KP
I/We confirm that I/we am/are submitting this Proposal Form after having read and understood the product features, benefits & risk factors, structure of charges, terms and conditions of the proposed plan as
set forth in the related brochure(s) and I/we submit the duly acknowledged sales illustration confirming my/our understanding of the plan for which this Proposal Form is being submitted.
I/We declare that I/we have answered the questions in the Proposal Form after having fully understood the nature of the questions and the importance of disclosing all information while answering such
questions. I/We also hereby declare that the answers given by me/us to all the questions in the proposal form are true and complete in every respect and that I/We have not withheld any material information or
suppressed any fact. I/We undertake to notify Kotak Mahindra Old Mutual Life Insurance Ltd. (“the Company”) of any change in the state of health of the life to be insured or as to his/her occupation or any
decisions about his/her existing policies or proposals subsequent to the signing of this proposal form and before the acceptance of the risk by the Company. I/We hereby consent to the Company seeking
information and any reports from any doctor(s) including hospital - who at any time may have attended to me/us concerning anything, which affects my/our physical or mental health.
I also hereby authorize my employer, to divulge to the Company any information required by it in connection with this proposal form and the policy contract that may be issued pursuant to this proposal. I agree
to undergo all medical tests required by the Company for obtaining the policy. Further I understand that in the event of my being physically examined, the answers given by me to the medical examiner acting on
behalf of the Company, shall be deemed to be duly incorporated in this Proposal Form. In event of this proposal not being converted into a policy the Company reserves the right to recover from me
administration charges and medical expenses incurred by the Company.
I/We further declare that the statements/submissions made by me/us in this Proposal Form [including any addendum(s) thereto / all declarations, affidavits and other statements] and/or any information
sought for by the Company from any person authorised by me to provide such information, relied upon by the Company to assess the risk on my life under this Proposal Form shall form a basis of the contract of
insurance between me/us and the Company. And if any untrue statement is contained in the Proposal Form [including any addendum(s) thereto]/any of the above documents or statements, or if there has been
a nondisclosure of a material fact the Company shall have the right to vary the benefits/ treat the Policy as void and all premiums paid under the policy may be forfeited to the Company.
I/We understand that the contract will be governed by the provisions of the Insurance Act, 1938, the IRDA Act, 1999 and the Regulations framed there under and that the contract will not commence until the
Company's written acceptance of this Proposal Form is received. In case of the life to be insured being a minor, I further declare and affirm that this proposal of insurance is for the benefit of the life to be insured.
I/ we hereby confirm that all premiums will be paid from bonafide sources and no premiums have/will be paid out of proceeds of crime related to any of the offence listed in Prevention of Money Laundering Act,
2002.
(Applicable for non tobacco users opting for Kotak Preferred Term Plan or Kotak Preferred Term Benefit )
I hereby declare, that I have not consumed tobacco in any form (smoking, chewing etc.) during the past 12 months and do not have any intention of consuming tobacco in any form in the future. I am aware that
any false statement regarding my use of tobacco would render the contract void and lead to loss insurance cover.

Please paste latest

self-signed Signature / Right Thumb Impression of the life to be insured Signature / Right Thumb Impression of the Proposer
photograph (or Guardian, if the life to be insured is a minor) ( if different from the life to be insured)
of the Proposer

Place Place

Date D D M M Y Y Y Y Date D D M M Y Y Y Y

14. DECLARATION FOR ONLINE TRANSACTION RIGHTS:

I have read the terms and conditions of registration on Kotak Life Insurance website – www.kotaklifeinsurance.com and Place
accept them. I agree that all transactions executed over the website www.kotaklifeinsurance.com under my username Signature / Right Thumb
and password will be binding on me. I understand that I get transaction rights for proposal number mentioned above Impression of the Proposer
Date D D M M Y Y Y Y
provided my application is accepted by Kotak Life Insurance.
15 DECLARATION BY THE PERSON FILLING IN THE FORM (Applicable only where form is filled in by a scribe or signed in vernacular languages)
I, ___________________________________________________________ (Full Name) have explained to the Proposer, that the answers to the questions form the basis of the contract of insurance
between the Company and the Proposer and that if any untrue statement is contained therein the Company shall have the right to vary the benefits which may be payable and further if there has been a
non-disclosure of a material fact the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company. I also confirm that the Life to be Insured has signed / affixed
his/her right thumb impression in my presence.
Address
Village/ District Land Mark
City State Pin
Place Telephone No. Date D D M M Y Y Y Y
I, the Life to be Insured / Proposer declare that the contents in the proposal form and documents have been fully explained to me and I have fully understood the significance of the
proposed contract.
Signature / Right Thumb Impression of (Signature of the Life Advisor/Specified person of Corporate Agent
Signature of the Scribe
the Proposer /Authorised Employee of Broker/ Relationship Officer)

16. DECLARATION BY THE LIFE ADVISOR/CORPORATE AGENT/BROKER/ RELATIONSHIP OFFICER (please cancel what is not applicable and fill all details)
I, ________________________________________________________ (Full Name) in my capacity as the Life Advisor/Specified Person of the Corporate Agent/Authorised Employee of the Broker/
Relationship Officer, do declare that I have explained all the contents of this proposal form, including the nature of the questions contained in this proposal form to the proposer. I have also explained that
the statement(s), information and response(s) submitted by him/her in this proposal form to questions contained herein or any details sought herein will form the basis of the contract of insurance between
the Company and the proposer, if this proposal is accepted by the Company for issuance of a policy.
I have further explained that if any untrue statement(s)/information/ response(s) is/are contained herein / including any addendum(s), affidavits, statements, submissions furnished / to be furnished, the
Company shall have the right to vary the benefits which may be payable and furthermore if there has been a non-disclosure of any material fact, the policy issued in his/her favour pursuant to this proposal
may be treated by the Company as null and void and all premiums paid under the policy may be forfeited to the Company. Based on my interaction with the proposer and/or the documents and records
that I have been supplied with, I have no information, which suggests that any of the statement(s), information and response(s) supplied by the proposer or the life to be insured is/are incomplete or untrue

Licence No. (Life Advisor/Corporate Agent/Broker/Relationship Officer)

Place
(Signature of the Life Advisor/Specified person of Corporate Agent
Date D D M M Y Y Y Y Telephone No. /Authorised Employee of Broker/ Relationship Officer)

FOR OFFICE USE ONLY CHECKED BY

NAME OF SALES MANAGER NAME OF SALES ASSOCIATE PROMOTION CODE NAME OF BOE

SALES MANAGER ID SALES ASSOCIATE ID PARTNER CODE BRANCH NAME

D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y

SIGNATURE OF SALES MANAGER SIGNATURE OF SALES ASSOCIATE SIGNATURE SIGNATURE OF BOE

Kotak Mahindra Old Mutual Life Insurance Ltd.

Regn. No. 107, Regd. Office: Kotak Mahindra Old Mutual Life Insurance Ltd., 9th Floor, Godrej Coliseum, Behind Everard Nagar, Sion (East), Mumbai - 400 022.
www.kotaklifeinsurance.com
Insurance is the subject matter of the solicitation.
PF01-0503-ENG/V1.6/PRN/150K/06/JAN/10/001/AL/1/HO