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Customer Consent Document Avoid Policy Rejection. HDFC

(CCD) - Other Channels
ADDENDUM TO ELECTRONIC PROPOSAL FORM
Fill out this form
carefully.
Life
Saf ut;ka_ ke .. o!
Application Number SALES PERSONNEL'S SIGNATURE$
(Electronic ixooosot form ID nlJmber) I, HDFC Life agent have ensured that this form is completed after
discussing and agreeing on the proposed insurance plan.
Inill-I 1111-111
TO BE FILLED BY THE CUSTOMER
Type of insurance Plan: --, Protection II Investment --, Pension --, Savings 1- Health Cover I Combi Plan
(tick correct cotton) l..!:. I L.!!. I I I
• Name of Insurance Plan • The premium payable is ~ CUL_jL_jL_jU_1
on a (S/MlQ/HY /Y) : frequency for a premium paying term o(J::J years & the Sum Assured is ~ ::JC::JC::JC::JC::JC::JC::J

• Have you filled the electronic proposal form ::J I has a third party or sales official assisted you in filling the proposal form vide above
application number?
::J (tick if yes)

_j (tick if yes)
• Do you agree to the Illustration signed byyou I received by you on youremaillDwith above application number?
• Do you agree to all the Terms and Conditions mentioned in the electronic proposal form vide above application number? ::J (tick if yes)

• Have you understood

these Policy details:
DEATH
BENEFIT
D .. (tlCkifyes)
MATURITY
BENEFIT' _
..
(tKkifyes)
LOAN ..
DETAJLS'A_(ticldfye)
HEALTH r- . .
BENEFITL- (tfckifyes)
# Not applicable for Term Policies
, Not applicable for UUP Policies
* Not opplicable for limited & regular
• Have you understood the Policy provisions with regard to Pre-Closure/Surrender?* ::J (tick if yes) Term Policies
• This application is for a fresh insurance Policy and is neither linked with an existing
Policy nor with any other financial products like credit card, loan, etc
I (tick if

yes)

• For Unit Linked Policy (ULlP),

have you understood:
DEDUCTIBLE CHARGES (tick if yes) _j
PARTIAL WITHDRAWAL FACILITY (tick if yes) U
I /We have been explained the features of this plan and understandthatthis is nota Fixed Depositor Recurring Depositbutan Insurance Plan.
II We understand that the returns in Unit Linked Products may not be guaranteed and are subject to investment risks associated with capital
markets. Are you atax residentof India only as per the Indian Income-tax law? I Yes I No (If No, please submit relevant documents)
I/Wewould liketo receive a Dematerialized Policy C Yes ~No (If Yes,please submit relevant documents)
1/ We understand that I/ We may receive calls from HDFeLife in relation to this proposalforinsuranceorthe resulting Policies. I/Wegive my consent to HDFCLife to make such calls even
when
I am /We are registered on NONe registry.
II We allow HDFCLife to use my Bank account details shared by me via cancelled cheque or NEFT details provided bySourcing Channel for any future payouts.
I/We agree that the answers to the above questions are true and that this addendum forms a part of the proposal/contract between me/us and HD FC Life.
II We give consent to allow Sourcing Channel tofurnish mycredentials/information (address, contact no, emaiIID.loandetails, income & nominee) as pertheir/h isl her records& vice versa.
1/ We declare that the content of the form and document has been fu lIy explained tome and II We have fully understood the significance of the proposed contract.
1/ We agree and understand that the insurance plan purchased ison the basisofthe need analysisdoneand assuggested by Suitability Matrix.(if
applicable) I/Weagreeand cnderstendtnetrne combiprotJuctisjointly offeretJ byApolloMuni(hHeolthlnsuronceCo. ua. ondHDFC Standard UjefnsuronceCo. Ltd.
(HDFCLi/e)

Life to be Assured zC I Proposed Policyholder D I Appointee*C

Life to be Assured 1: (tn((JSf;!l)j itJir'" NjpJXOjJ()SlJl) (If ("/J?tE>rlijrom life lO bE?rr.;w((!rJ) ber>':>fi'dory Is () miriQI)
(!Vomi/leel

Ensure you know all Policy details CUSTOMER'S SIGNATURE

CUSTOMER'S SIGNATURE

Name: Name:

Date: Place: _ Date: Place: _

• If the nominee I beneficiary is a minor, a person should be appointed to receive the amount secured by the Policy in the event of death of the life to be Assured during the
period when the nominee is a minor. (Pleaseattach appointee deciarationforEmployer-Employeecase)
r-------------------~-----------------------------------------------------------
--------------------------~----------------------------------------------------------------------~---------------------------------------------------,
SI/ECS/NACH Ma ndate (Below details to be filled only if SIIECS is opted for)
"HDFC
"Life UMRN 1 1 1 DateL_ o=J ,-I -'--

Sponsor Bank Utility Code

Code

IIWe hereby authorize H_D_F_C_L_IF_E to debit (tick .1') SB/CA/CC/SB·NRE/SB-NRO/OTHER

Bank alc num ber L IL.._IL.._IL.._I.J..._.JI ..._.IJ..._.JI -,-I -,-I -,-I -,-I _J__I ---,--I--,-I---,-I---,-I---,-I---,-1---1.1---1.1--'.1--'.1_-----,
..._-I,--I
J_.I..L....I.L.-.,I-I
withbankL- ~==================================~I~FS~C~==========================~o~r~M~I(~R~~I ~==================::

FREQUENCY ~ '10PJTIILY ~ Otl) ~ II.V:I; ~)"'Ij 121 As & hen presented DEBITTYPE X' Fixed PtPl'le!lSllt ZI Maximum Amount
ReferenceNo.l w --' Mobile No. '- _

Reference No. 2 ~_,-- -,--,-------, ---_,_-_,_ -_,_.,.,._------ J EmaillD '--,- ,-------------------

1.1gr~efor the debit of mandate procsssinq charqes by the b.lnlcwhoml amauthorizilq todebit mt cXCDlSltas perlatQSl sd'tedule of chan~~ of the bank.
PERIOD
 From I r II r I I
To ~1~1~1xIx1
Or /l Until Cancelled
1. 2. 3.

This is to confirm that the declaration/terms has been carefully read, understood and made by me/us.1 am authorizing the User entity /corporate to debit myactount.
I h~v;:ol)fldef<;lOl)d thall ~m dtllhn(j/ed to (cH)(el/cl(lwrI<llhio; m~ndate by df)p(l)J)ri.aleIY(Ofnm.ril dtir)!:Jthel dnl e'dlionld(JwnPf)Cieooenl reQUE>Slto lhe~(E>nlily/(orf)Ordt ...(If lhp bank v..hen:: I haV@dIJlh(l(i7ed lh .. (lelJil
 pagez/zf
oc 21/8/2017·4.0
Application No.: DDDDCIJDDnlTTTl MyMIX Code:
PAYMENT DETAILS
• Mode of Payment: Cheque D DoD Net Banking D Debit Card D Online/Offline Credit Card D
Others D please specify
• Initial Payment has been made from account I Debit Card / Credit card that belongs to:
Self D SpouseD Parent D ChildrenD SiblingD Grandparent D Partnership D Company D
HUFD TrustD OthersD please
specifY
• In case of Third Party Payor, enclosing Third Party Declaration & KYC D
CONSULTANT CONFIDENTIAL REPORT (CCR)
Name of life to be assured
Do you have any information of the Life to be assured having suffered from any illness or injury or undergone any operation, surgery or medical
n
examination in lastS years? Yes I No
If'Yes' please give details:
I hereby declare that I have personally met the life to be assured and all statements mentioned above are true and correct to the best of my knowledge and belief. I
have complied with the Code of Conduct as stated in regulations framed by the Insurance Regulatory & Development Authority and the provisions of my contracts
with the Company applicable to the policy to be issued. I herby confirm verifying the copies of all the documents submitted herewith against the originals. I hereby
confirm that the applicable AMLand KYCguidelines have been adhered to, to the best of my knowledge and the current/permanent address have been verified by
me.
I 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 byhimlherin this proposal form to questions contained herein oranydetails sought herein
will form the basis of the contractof insurance between the company and the proposer. if this proposal isaccepted by the (ompanyforissuance 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.
submission 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 maybe forfeited to the Company.
 SALES PERSONNEL'S SIGNATURES
Consultant's Name

I I I I
II
Consultant's Code DDDDDDIT]I I
Branch
Date Place
DECLARATION BY Circle Head I TM &- Above (for policies sold to > =60 years Life Assured I Payor I Proposed Policy Holder)
I confirm that I have spoken to/met the customer for this life insurance proposal, I confirm that the customer is aware of all product features and that
the policy issold in line with the customer's requirements. Thepremium paying capacity of the customerforthe said proposal has been established.
SIGNATURE

I :~:yee Code DDDDDDDITJI I I I II

II
DECLARATION BY SAlES CONSULTANT & THIRD PARTY
• I hereby declare that I have explained the contents of this application form and Ihave also explained all the important features of the HDFCLife insurance plan
to address the customer's need. I have thereby ensured that the same is completely understood by the life to be assured in language and
have truthfully recorded the answers provided to me .
• I further declare that the life to be assured / proposed Policyholder has signed / affixed his I her thumb impression in my presence.
Sales Consultant: SIGNATURES
Name:
Code: DDDDDDDDDDCIJD
--- - -- - -- -- - - - - - - -- - - - -- - - - - -- - - -- - - - - - - - -- - - -
Date: Place:
. - --------- ---- ----------------------------------------------------------------------------------------------------_. I
--T -h --ir -d - P-- a- r--t y- :- (-A- p-- p- ilc-- a- b- l- e- -w -h - e n s o l ic i t a t io n d o affixedI signaturedoneinregionallanguageby
n e in r e g io n a l a n g u a g e o r t h u mbimpression
Name: customer) SIGNATURE
Address:

, Sales Hierarchy Date: Place:

II
to fill in & sign the form, it SP / BC/ FC / Sales Personnel is the life to be assured.
Note: 1. Please fill Consultant Confidential Report (CCR) on POS 2. Third party Is an Individual who Is not the life to be assured or sourcing personnel

-------~--------------------------------------------------~--------------------------------------------------~>------- -
Renewal Payment has been made from account I Debit Card I Credit Card that belongs to:
Self D SpouseD ParentD Children D Sibling D Grandparent D Partnership D Company D
HUFD Trust D OthersD please specify
DECLARATION:
1.11 We herebydeciare that the particulars given above are correct and complete. 2.llWe hereby declare that in case of athird party account holder, a KYCform ofthe account holder shall be submitted. 3.11 We
undertake to keep sufficient funds in the account mentioned in the mandate as on the date of execution of debit 4.11 We hereby authorise the Bank I Tech Process Solutions ltd I Bill desk I any other
intermediaries to communicate my lour funding account number and any other account details (as may be necessary) to HDFC Ufe Insurance Com(>any Limited (H DFC Life) for the specific purpose of
recovering my I our HDFC Life premium payments through a debit instruction to my I our account. S.IIWeherebyauthoriseHDFC Life, in the instance of the ECS/SI/DDINACH failing for any reason, to authorise
the Bankl Tech Process Solutions Ltd IBi II desk to recover the premium payable through a direct debit to my/our account with the mentioned bank. 6. If the transaction is delayed or not effected at all for
reasons of incomplete or incorrect information, Iwill not hold HDFC life, the Bankor the other Intermediaries responsible. 7. VWe agree that for changing the premium amount as per my requirement I/We will
furnish a fresh mandate for such change in the premium amount. which will supersede all other mandates previously given. B.1t We agree that in the event of any violation by mel us of any undertaking
confirmed in the aQreement herein, shall amount to an event of default in the termsof the Insurance Policy and HDFC Lite snail been titled to invoke the remedies available to it in termsof the Policy agreement.
9. II We agree that In the event of the Bank being unable to debit my account for want of sufficientfundsorfor anyother reason, HDFC Life shall be entitled to deal with my Policy in the manner as described in
the Policy provisions, unless the payment is received by any alternate mode on or before the specified date.ID. VWeherebyauthorisemyl our Bank to debit my I our accountwittithe amount of taxes and other
levies as maybe stipulated by the Government, from time to time, on the premium stated abOlie and forthis purpose, no furtheror revised authority is required by myI our Bank.l1. IIWe hereby authorise that in
the instance of a transaction failure towards an ECSrequest, HDFClife can represent twice the transaction to my louracrount forrealising this premium. 12. I/We wish to avail the ECS/SIIDDINACH facility and
hereby express my uncond itional consent to debit premium of my Policy to abOlie through participation in ElectronicClearing System (ECS)IDirect Debit. I/We understand and agree that premium amountro be
debited from my account may vary due to taxes and otherstatutory leaves as may beappllcable from time totime.13. II We understand andaccept that the transaction will be effected on the Policy on the due
date (provided the day isaworking day).I/We a!lree to discharge theresponsibihtyexpectedof mel usasparticipants under the scheme. Itake full reSf)onsibility of correctness of the details filled ~erein.14.11
We authorise the above mentioned bank to debit my bank account if mylour ECSmandate is active and until I giveawritten request for cancellation of ECS/SI/DD/NACH.15.ln the future, if IIWe opted out of
E(S/Direct Debit mode there may be on increase in premium amount.16. VWe understand and agree thot the submission Of thiS form does not mean that the request will be processed. II We understand mat
any payout under the Policy shallbe strictly in accordance with the Policy termsand conditions. Afso, any paymentshall be subject to realisation of the last renewal premium payment .17. II We also understand
and agree that the Company reserves the right to use any payout option. 18. FarSI with HDFC Bonk/RatnakarBonk. premium will bedebited from your account on the debit dote. However. if the 1st attempt is
unsuccessful, 3 more attempts will be made within grace period. 19. vWe authorisetheabOliementionedbank todebittheamount from my bank account if my ECS/SI/DD/NACH is active. until Igive a written
request for cancellation of the Mandate.
Important Note:
1. Any cancellation, correction. alteration etc. should be countersigned by the Account Holder. 2. For SI cases (HDFC BonklRatnakar Bonk), the NAV allotted will be the date on which the bank gives a
confirmation ottne debit. 3. For ECS,NAV would be allocated on the basis O(thedebit dateA. Dire<:tdebit facility{non ECSlocation) is offered by ICICIBonk, Ciribsnk. Union Bank of India. Bank of Baroda. State
Bankof India,Axis Bank, Punjab National8ank and J&K Bank only. 5. For OirectDebit NAVwillbeprovidedforthedaywhen the payment is received inthe HDFC Lifeaccount. 6. Requestfor de- activation of Auto
debit facility has to besubmitted atleast15 days priortothe next premiumduedate.7. Thepremiumwill bedebite<lstartingfrom the premium due dote which occurs atterthe dote of this mandate. Till the last
premium due date unless the mandate is revoked. 8. In case of any increase or decrease in premium amount due to changes in payment frequency or any Policy related changes including reduction in
premium', the existing debit instruction will be ce-ecnveteo. Hence. a fresh Auto Debit Mandate isrequired to be submitted at any HOFC life branch at least 30 days prior to the next premium oue date. 9.ln
caseof PBD option the NAV will be allocated as per preferred billing date and not premiumduedate.10.Grace period in case of PBDwillstartfrompremium due date only and not from Preferred billing date.
* Reduction in premium isa product-specific alteration.
IlOfC Standard Life Insurance Company Limited. In partnership with Standard Life Pic. CIN:C99999\H 12000PLC I28:?45. IRD AI Registration No. 101.
Regd. Off: Lodha Excclus 13" Floor, Apollo Mills Compound, K. M. Joshi "{arg, Mahalaxmi, Mwnbai - 400 0 I l , For qucrics ormorc information, call us on 1860-267-9999 (Local charges apply).
DO 'JOTprcfix any country codc c.g. -91nrOO. Available Men-Sat from lOam 10 7 pm TImail-sernce@hdfclife.enm INRIservice@hdfclife.c.om(Pol''JRl customers only) I Visu-www.hdfchfe.com