FINANCIAL ASSESSMENT FORM- ver 1.1

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1 - ver 1.1 Mandatory Annexure (Any of the mentioned list) Last 6 Months Bank Statement / J Forms or Agricultural Sale Receipts / CA Certificate of Personal Assets and Liabilities/ Investment Portfolio Statement / Proof of Investments Greater than Rs. 20 Lakhs Section I: General Information Mandatory for all Section II: Financial Information Mandatory for all Section III: Female Financial Profiler Mandatory for Female lives (Except for Salaried and Professionals ) Section IV: Business / Partnership / Proprietor Mandatory for Business / Partnership / Proprietary concerns Section V: Bank Assessment To be completed by the certifying Bank (Mandatory for Bank Assurance and Agency Cases) Section VI: Agricultural Income To be completed if Agricultural income is a part of income disclosed Section VII: Surrogates As and when Applicable with supporting documents Section VIII Certificating agency needs to justify the Proposed cover (Mandatory ) Section IX Declaration by PI/PO Section X Declaration by Sourcing /Certifying Agency Certificate of Agricultural income To be completed if Land ownership record or form 7/12 is not submitted (refer section VI) Important Points Details of Acceptability and Validity Note: If the mandatory sections are not completed, the form is liable to be rejected at UW Financial details for Proposed Insured (PI) have to be provided in all cases. Where PI is earning and PO is the premium payer, TWO separate Financial Assessment Forms should be provided Section I: General Information (To be completed by all) Instructions: 1. Section I: General Information : All fields are mandatory except under the following: a. PAN Number: If PAN number has not been provided / NRI / People from Tax Exempt areas (Please indicate scheme under which exempted). Persons applied for PAN Card, to provide the acknowledgement form. b. Official ID (other than salaried) Application Number Name of the Life Assured Name of the Proposer (If different from PO) The Form indicates income of the PI / PO (Please Select only one) Proposed Insured Policy Owner Pan Card Number/Refer instructions if Pan Card not available Official ID (In case of salaried) / Company Website Existing Cover Total Cover of the life Assured with Met Life Total Cover of the life Assured with other Insurance Companies Cover details of 1. Spouse 2. Parents 3.Siblings Section II: Financial Information (To be completed by all) Minimum of Last 2 year s financial information should be provided. *Business income: Section IV to be completed; Agricultural Income: Section VI to be completed. Name of the Company Employed / Business / Partnership/ Proprietary concern Annual Income from All Sources (Please mention the Assessment Year in the space provided) Assessment Year Current Year: 20 Last Year: 20 Previous Year: 20 Income From Salary Business income* Agricultural Income* Rental Income Others Estimated Income As Per ITR Estimated Income As Per ITR Estimated Income As Per ITR Page 1 of 6

2 Section III: Female Financial Profiler Mandatory for Female Lives Does the Proposed Insured hold any of the following documents? Name of the Document Document Number Tick the appropriate Pan Card Yes No Passport Yes No Credit Card Yes No Driving License Yes No 1] Is the business a family held business? 2] How many hours are spent by the PI looking after the business and how long PI has been involved in the business? 3] Income generated from business that can be shown as PI s contribution: 4] Exact nature duties and complete address of business: Section IV Business / Partnership / Proprietor (Mandatory for Business / Partnership / Proprietary concerns) All fields are Mandatory. If the client has stake in multiple companies, please attach a separate sheet indicating the details as below. Name of the Company: Percent Share of Profits in the company: Assessment Year Current Year: 20 Last Year: 20 Previous Year: 20 Total Sales / Gross Receipts Total Assets Total Liabilities Net Profit before Tax Net Profit after Tax Depreciation Section V: Bank Assessment (To be completed by the Sourcing Bank in ALL Cases or by ALL Clients with Investment Income) All # marked fields are mandatory. (Refer Point 3 on the Instruction sheet) Primary Account Holder (Please Tick the appropriate) Life Assured Policy Owner Date of Opening Account # DD MM YY Account Number # Type of Account (Please tick) Priority / Salary / NRE / NRO / Other (Please specify) Average Amount of transaction per month (Debit / Credit) # Average Assets under Management in the Past 12 months # Details of Investments and Liabilities Fixed Deposits Personal Loan Shares Home Loan Mutual Funds Business Loan Cash Credit Overdraft Page 2 of 6

3 Section VI: Agricultural Income (To be completed if Agricultural income is a part of income disclosed) All fields are mandatory. Please attach Land Ownership Record / Form 7/12 / MetLife Certificate of Agricultural Income (Refer to Page 5) Ownership of the land in the name of: Self / Joint with... Survey No of the Land : Number of Acre / Gunta: Variety of Crops Grown Amount of Yield Income Generated Section VII: Surrogates (As an when Applicable with supporting documents) Credit Card Name of Issuing Bank Name / Type of Card Credit Limit Model Year of Purchase Value of the Car Car Club / Prestigious Memberships Name of the institution Any Particular Post held Land / Property Ownership Name of the Land / Property Type Size details Sale amount Section VIII: Justification of Cover Applied for (To be completed by the sourcing agency) Please refer point 2 in Important Points section for the HLV multiples for term and Investment products Average Annual Income X HLV Multiple for the Customer = Maximum Eligible Cover Any Other Justification: Have you filed for bankruptcy or currently have any financial proceeding against you? Yes / No Page 3 of 6

4 Section IX: Declaration of the Policy Owner and Proposed Insured: I hereby declare the above mentioned facts are true to the best if my knowledge and I give consent to consider the above mentioned facts as a part of the contract of Life Insurance application with MetLife India Insurance Name of the PI/PO Date Signature of the PI/PO Name of Witness Signature of the Witness Date Section X: Declaration of the Sourcing/Certifying Agency (Please select the appropriate): (A) I hereby declare that the above mentioned facts vide section V are based on the Bank Records and the recommendations are based on the same along with Proposed Insured s declaration attached along with. I have explained the Proposed Insured that the MetLife Assessment Form for Bank Customers would be forming a part of the contract for his /her application with MetLife. Name and Designation* of the Signing authority on behalf of the Bank with date & Bank seal (Branch Manager and Above) (*Local Branch Manager/ Operations Manager and above are authorized to sign the Declaration.) I hereby declare that the identity of the customer as well as his / her good health has been personally verified by me and that I recommend acceptance of the application considering all the factors, including moral hazard. Name and Signature of the (B) Moral Hazard Report Met Royale FA CA Name with Membership Number Sales Manager/Agency Manager or Territory Manager /Area Manager or Regional Manager * *Signature as per Grid of Signing Authority should be done for all cases Sales Manager AFYP <10 Lacs Agency Manager or Territory Manager AFYP >=10 Lacs & <25 Lacs Regional Manager or Area Manager AFYP >=25 Lacs (C) I hereby declare that the recommendations are based on my independent verifications along with Proposed Insured s declaration attached along with. I have explained the Proposed Insured that the MetLife Financial Assessment Form would be forming a part of the contract for his application with MetLife. Appropriate signatory to complete this section Signature and Seal: Signature of Met Royale FA : Employee No/ Registration no *: FA code : Date : Place : Date : Place : *Employee No Branch Manager of Bank & above/sales Manager/Agency Manager/Territory Manager/Area Manager/Regional Manager Registration No Applicable for CA Page 4 of 6

5 MetLife India Insurance Company Limited CERTIFICATE OF AGRICULTURAL INCOME (PART 1) Certified that Sri / Smt Son / daughter / wife of is the absolute / joint holder of agricultural lands described below and that his / her annual income delivered from that property for the last three Revenue years is estimated as given below. Village : Survey No : Name of the Joint owner if owned by more than one : Nature of crops grown Whether irrigated If irrigated, Source of irrigation Extent (area) Acres Acres Acres INCOME derived for the last three years Year Year Year This certificate is issued on the basis of information available in the Taluk office obtained after due enquiries through concerned Revenue Inspectors. Date: Signature of the Tahsildar/ MRO/ Agricultural Officer Office Seal (Note: 1. A separate certificate in respect of each village shall be issued.) Page 5 of 6

6 Important Points: 1) Investment Portfolio Statement / Proof of Investments Greater than Rs. 20 Lakhs are not acceptable as Income proofs under AML guidelines. Hence separate income proof may be required for AML purpose 2) Please refer the below table for answering Section VIII. INVESTMENT PROD TERM PRODUCT AGE >65 AGE BUSINESS/PROFESSIONAL /SELF EMPLOYED BUSINESS/PROFESSIONALSELF /EMPLOYED SALARIED SALARIED ) Validity of Financial Assessment form: FAF is valid within one year from date of login; however a fresh FAF may be called based on a case basis. 4) Mandatory Documents / Information: If any of the mandatory information is missing, the underwriter needs to assess the form, application and all other documents available. basis this assessment the Underwriter may justify the HLV or PPC without requiring the said missing information. However, if the underwriter is unable to justify the HLV or PPC, the said information may be asked along with any other evidence as required. Annexure: $ Wherever Underwriter can justify the HLV or PPC based on the available information and document the said document / information may be waived SL Description Mandatory $ Document 1 FAF Annexure Yes Any of Last 6 Month Bank Statement / Investment Portfolio Statement / Proof of Investments Greater than Rs. 20 Lakhs / J Forms or Agricultural Sale Receipts / CA Certificate of Personal Assets and Liabilities 2 Car papers as surrogates Wherever Declared Either valid Insurance papers or Car registration papers 3 Rental Income Wherever Declared Rental Agreement 4 Public announcements No Available Newspaper or Internet information regarding the profile of the client 5 Credit card as surrogates Wherever Declared Copy of front of the credit card or latest credit card statement 6 Land or Property Sale/Ownership document Wherever Declared Copy of the Land / Property sale registration papers Page 6 of 6

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