APPENDIX-1

DECLARATION BY THE LIFE TO BE INSURED, PROPOSER AND IN CASE OF MINOR, BY HIS/HER LEGAL GUARDIAN

I/ We _________________________________________________________ request you to accept Proposal Reference Number ______________________________________________ for

PRODUCT NAME
______________________________________________________submitted by me/ us on Digital Application of Kotak Mahindra Life Insurance Company Ltd. during my meeting with your
relationship manager _________________________________________ bearing License No. ________________________________________________________.
I/We declare that I/we have 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).
I/we also acknowledge having read Benefit Illustration No. _____________________________________ confirming my/our understanding of the plan for which this Application is being submitted.
I/We hereby confirm that Mr./Mrs._______________________________________________has duly filled the details in the Proposal on the Digital Application in my/our presence and on my/our
instructions.
I/We ________________________________________________(name of LI – in case different from Proposer) declare that I/we have answered the questions in the Proposal truthfully after having
fully understood the importance thereof. I/ We acknowledge that the information stated in the Application with regard to Life to be Insured’s health history/habits/or any treatment taken in the
past/hospitalization for more than 5 days due to any disease/illness and the same is true and correct and I/We have duly checked and verified the same and that I/We have not withheld any material
information or suppressed any fact.
I/we understand and agree that by submitting the Application and addendums, if any, I/we will be bound by such statements/ disclosures of material facts in the same manner and to the same
extent as if I/we have signed and submitted a written proposal for Life insurance to KLI.
I/We also undertake to notify KLI 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 the Application and before the acceptance of the risk by KLI.
I/We hereby grant consent to KLI for seeking information and any reports from any doctor(s) including hospital who at any time may have attended to the life to be insured concerning anything,
which affects the life to be insured’s physical or mental health. I also irrevocably authorize KLI to approach me by making telephone calls or through other means in connection with this policy or
otherwise. I further authorize KLI to share the details my Policy with Govt. authorities, other Insurance Companies, Credit Information companies or other entities.
I/we further authorize KLI to obtain my/our demographic details from Unique Identification Authority of India (UIDAI) on the basis of Aadhar No. provided by me/us in the above mentioned
Proposal submitted by me/ us on Digital Application of KLI and use the same for all purposes in connection with the said Proposal or the Policy issued pursuant thereto.
I/We agree to abide by the provisions of S. 41 of Insurance Act, 1938. I/We also agree that in case of mis-statement of fact/ fraud/ misrepresentation/ suppression or non-disclosure of material fact
by me/us, KLI reserves its right to cancel the Policy or declare the Policy as null and void in accordance with Section 45 of the Insurance Act, 1938.
For existing customers of Kotak Mahindra Bank (KMBL): In case of a mismatch between my/our details pre-filled from my Kotak Bank CRN and those available in Kotak Life, I/we give consent to
Kotak Life to use the data pre-filled from Kotak Bank CRN for the purpose of this policy as well as all existing Kotak Life Polices.
DECLARATION FOR PRODUCT SUITABILITY
I hereby confirm that I have taken the product suitability by filling the product suitability questionnaire. I also confirm that product selected by me for insurance is with complete understanding of all
its features, benefits, premium, and risks associated with it.
DECLARATION FOR ONLINE TRANSACTION RIGHTS:
I have read the terms and conditions of registration on Kotak Life Insurance website - http://insurance.kotak.com and accept them. I understand that I will have to register on
http://insurance.kotak.com to receive my username and password. I agree that all transactions executed over the website http://insurance.kotak.com under my username and password will be
binding on me. I understand that I get transaction rights for proposal number mentioned above provided my application is accepted by Kotak Life Insurance. I hereby authorize Kotak Life Insurance
to make call or send SMS to me in relation to any transactions or servicing pertaining to my proposal / policy, despite a contrary preference indicated by me under TRAI Regulations.
Declaration for MWP:
I (proposer) shall have the right to appoint new trustee(s) by revoking the appointment of the existing Trustee(s). Further, I agree that no loan can be granted against security of this Policy. However,
the Trustee(s), with the consent of the Beneficiaries/guardian, can make a request for loan for the use/benefits of Beneficiaries.
ORIGINAL SEEN AND VERIFIED:
Photograph of my/our below mentioned original documents have been taken and
uploaded on the Digital Application in my presence by the agent above named:
1. Proof of Identity -
2. Proof of permanent residence - Date:______________
3. Proof of current residence -
4. Proof of Income - Place:_____________
5. Source of earning- Signature of Proposer
Date:______________

Is FATCA/CRS applicable to you? Place:_____________

Signature of Life to be Insured
No, it is not applicable. I am a resident Indian.
Date:______________
Yes, it is applicable. I confirm that I have provided all relevant details, and read and understood all
terms and conditions in the KLI Genie digital sales application and I agree to it. Place:_____________
Appointee Signature (if Nominee is Minor)
Date:______________

Place:_____________
Signature of Trustee
Date:______________

Place:_____________
Life Advisor ID
Date:______________

Place:_____________
Seen & verified the original AML & KYC documents
(To be signed by authorized KLI employee)

Signature of specified person & Seal of corporate agent / Signature of Life Advisor KLI SM Life Asia Code

SCRIBE DETAILS - Declaration by the person filling in this Customer Declaration Form (“CDF”) (Applicable only where the declaration is filled in by the scribe or signed in vernacular
language) I, ____________________________________ have explained to the applicant, the contents of this CDF and the proposal form submitted through the Digital Application of
KLI. I also confirm that the applicant has signed / affixed his / her right thumb impression in my presence.
Scribe’s relationship with Applicant: ___________________________________________________________ Mobile No.:_______________________________________
Address of Scribe:

Date:______________ Date:______________

Place:_____________ Place:_____________
Signature of Scribe : Signature of Applicant
Version 11.2

Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.); Regn. No.: 107, CIN: U66030MH2000PLC128503, Regd.
Office: 2nd Floor, Plot # C- 12, G- Block, BKC, Bandra (E), Mumbai - 400 051. Website: http://insurance.kotak.com I Email: clientservicedesk@kotak.com I Toll Free No:1800 209 8800.
Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.