Master Proposal Form for Exide Life Group Term Life (GTL/Version 2.0 dated 16-03-15) P F 1 1 1 1 1 1 MASTER PROPOSAL NUMBER: IMPORTANT NOTES TO THE PROPOSER: 1. Please fill the Proposal form in BLOCK LETTERS and disclose all facts. Any correction or overwriting in the Proposal must bear your full signature along with the seal of the Company. 2. You are required to disclose ALL material facts and circumstances in this proposal, which shall form the basis of the contract, Otherwise the policy issued shall be voidable at the option of the Company. If you are in doubt as to whether any of the facts and circumstances are material or not, you must disclose them. You may use annexures wherever required. 3. Evidence of Insurability will be required if the Sum Assured exceeds the amount of Free Cover Limit granted under the Group Insurance Scheme or Members do not meet the eligibility criteria under the Scheme. Besides, depending on the group size and/or eligibility criteria under the Scheme, Member/s need to be Actively at Work as defined in Part III. 4. Initial payment accompanying this Proposal must be made by a crossed cheque or through electronic transfer. The cheques must be issued in favour of EXIDE LIFE INSURANCE COMPANY LIMITED ACCOUNT (Proposal No. as above). Details for electronic transfer will be provided on request. 5. Receipt of the Completed Proposal and initial payment does not create any obligation upon the Company to underwrite the risk. The Company shall not be liable until it has underwritten the risk and issued the Policy. Part I : Details of Proposer and Coverage Information 1. Name of Proposer/ Company 2. Legal Status Firm/Company Sole Proprietorship Partnership Public Limited Company Private Limited Company Any other 3. Date of Incorporation : 4. Nature of Business : 5. Registered Office / Principal Office Address City State Country Postal Code Telephone No. Fax No. Email ID 6. Benefit Details A. Product Name (Base Plan) B. Riders Option A Group Term Life Insurance Plan Group Critical Illness Group Term Insurance Plan in lieu of PF EDLI A1 CI 4 Illness A2 CI 10 Illness A3 CI 25 Illness Option B Group Terminal Illness 50% 100% 7. Coverage Structure Base Plan A. Uniform Sum Assured of Rs. B. Formula Linked. Please Specify The formula: C. Graded. Basis of Categorization is as follows: A. Uniform Sum Assured of Rs. Riders B. Formula Linked. Please Specify The formula: Category Definition of Category No. of Lives Base Coverage Rider-1 Rider-2 Rider-3 I II III IV Page 1 of 6
8. Are all employees / members (in case of association groups) Covered? If NOT, Then %age of employees / members NOT covered and basis for exclusion Yes No 8a. Nature of employment/membership : Permanent Temporary Voluntary Others 9. Is any medical examination conducted at the time of recruitment, admission employment or acceptance of membership Yes No 10. Is any age proof insisted upon before admission of age in the office records Yes No 11. Are any medical or medical leave records maintained Yes No 12. Cost of Insurance scheme to be borne by Policy Holder(%) Member (%) 13. Desired date of commencement of coverage for Term products 14. Premium Frequency Annual Semi Annual Quarterly Monthly Single Premium 15. Mode of Payment Cheque Demand Draft Electronic Transfer Other Part II : Group Demographics 1. Eligibility Conditions: 2. Group Size: 3. Retirement / Member Cessation Age: 4. Minimum Age at Entry: 5. Maximum Age at Entry: 6. Cover for new members to be effective from: Date of Appointment Date of confirmation Date of joining Next Renewal Date Other 7. Any Special Requirements: 8. Has this group ever been covered by Group Life Insurance in any other company? Yes No If Yes, please state the name of the company: 9. Date cover ceased: 10. Please furnish details of lives to be covered under this scheme (Attach full list of employees/members as per the Annexure I) 11. Other current coverages provided (Please provide details as an attachment): GPA Mediclaim Gratuity Super Annuation Other Part III : Declaration and confirmation by the proposer 1. I/We, the authorized representative of the Proposer, do hereby declare that the statements made herein and answers have been given by me/us after fully understanding questions and the importance of disclosing all material information while answering such questions, I/We declare that answers given in the proposal form are true and complete in every respect. I/We agree that if any statement made by me/us is untrue, the company shall have the right to cancel this policy, if issued, and forfeit any payments received. I/We hereby declare that any personal information collected or held by the Company (whether contained in this proposal or otherwise obtained) is provided and may be held, used and disclosed by the Company to individuals / organisations associated with the Company or any selected third party (within or outside of India, including reinsurance and claims investigation companies and industry associations / federations) for the purpose of processing this Proposal and providing subsequent services and to communicate with Proposer for such purposes. 2. We undertake to notify the Company, forthwith in writing, any change in any of the statements made in the Proposal subsequent to the signing of this proposal and acceptance of risk and issuance of Policy by the Company. Page 2 of 6
3. We also confirm if any future premium or other payment due to the Company is made by us directly or through the Agent Advisor, then the Company shall not be liable unless the amounts are received and realised by the Company within the time the Company stipulates for receipt of the payments. 4( a). Applicable to Employer-Employee groups only: We certify that all Members are Actively At Work as per below. "Actively At Work" shall mean if on the date the coverage commences, the member is performing in the usual way, all of the regular duties of his/her job on a full time basis. If the member is absent on the date the coverage commences, due to illness, injury or maternity the coverage shall not commence until the date of his/her joining to duties and performing in the usual way all of the regular duties of his/her job on a full time basis and subject to signing a health declaration which is to be countersigned by the employer. Further, if the member is not at work on the date the coverage commences, solely because such a day is a regularly scheduled day off or a public holiday, he/she will be regarded as being actively at work subject to his/her satisfying the criteria of actively at work on the immediate next working day." 4(b). Applicable to Non Employer Employee groups only: We certify that all Members are Active Members as per below. Active Member declaration shall mean a statement provided by an Active Member he/she is active and performing his daily activities and all his obligations as usual on the Risk Commencement date. In the event if the member is suffering from any illness, injury or maternity case the Risk cover shall not commence until the member has recovered and is capable of performing his/her regular duties on a full time basis and also subject to signing a health declaration which is to be countersigned by the organization. (Authorised Signatory of the Proposer) (Signature of Witness) (The following person is authorised to complete claims documentation.) Signature: Name: Designation: Signature: Name: Designation: Dated this day of Free Look Period You may opt to cancel the Policy by returning the original Policy to the Company with a written request within 15 (fifteen) days from the date of receipt of Policy. In such case the Premiums paid less proportionate risk premium for the period of cover, any medical fee and expense incurred on stamp duty by the Company, will be refunded without interest to you. 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. Declaration by Agent Advisor - This is required as the product is proposed to be sold through Agent Advisor. I, declare that I have explained the nature of the questions contained in this Proposal form to the Proposer. I have also explained that the answers to the questions form the basis of the contract of Insurance between the Company and the Proposer 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 as void and all premiums paid under the policy may be forfeited by the Company. I confirm that I am not aware that the Proposer is engaged in activities including a 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 agents prescribed by the Insurance Act, 1938, The Insurance Regulatory and Development Authority Act, 1999, The Insurance Regulatory and Development Authority (Licensing of Insurance Agents) Regulation 2000, The Code of Conduct prescribed under Regulation 8 thereof and the Code of Ethics of the Company. I certify and confirm having seen the originals of the documents attached with the proposal form, self-attested by the Proposer and confirmed by me. (Agent Advisor's code / Broker Name) (Signature ) Place: Page 3 of 6
Section 41: Prohibition of Rebate 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 lakh rupees. Section 45 Fraud, Misrepresentation and forfeiture: Fraud, Misrepresentation and forfeiture would be dealt with in accordance with provisions of Sec 45 of the Insurance Act 1938 as amended from time to time. [A Leaflet containing the simplified version of the provisions of Section 45 is enclosed in Annexure (II) for reference] Annexure I SL. No. Name of Member Unique ID Gender Age at last birthday Occupation/ Designation Average Salary/Income(`) 1 2 3 4 5 6 7 Rider Option 8 Group Critical Illness Rider Sub-Option 9 Sum Assured In Force(`) Additional Sum Assured(`) Group Critical Illness Rider Accelerated Sum Assured(`) Group Terminal Illness Rider Accelerated Sum Assured(`) Premium (Base)(`) Premium (Riders)(`) Risk Commencement Date Nominee Name 10 11 12 13 14 15 16 17 Page 4 of 6
Section 45 - Policy shall not be called in question on the ground of mis-statement after three years: Provisions regarding policy not being called into question in terms of Section 45 of the Insurance Act, 1938, as amended from time to time are as follows: 01. No Policy of Life Insurance shall be called in question on any ground whatsoever after expiry of 3 yrs from a. the date of issuance of policy or b. the date of commencement of risk or c. the date of revival of policy or d. the date of rider to the policy whichever is later. 02. On the ground of fraud, a policy of Life Insurance may be called in question within 3 years from a. the date of issuance of policy or b. the date of commencement of risk or c. the date of revival of policy or d. the date of rider to the policy whichever is later. For this, the insurer should communicate in writing to the insured or legal representative or nominee or assignees of insured, as applicable, mentioning the ground and materials on which such decision is based. 03. 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 insurer to issue a life insurance policy: a. The suggestion, as a fact of that which is not true and which the insured does not believe to be true; b. The active concealment 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 fraudulent. 04. Mere silence is not fraud unless, depending on circumstances of the case, it is the duty of the insured or his agent keeping silence to speak or silence is in itself equivalent to speak. 05. No Insurer shall repudiate a life insurance Policy on the ground of Fraud, if the Insured / beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-statement of or suppression of material fact are within the knowledge of the insurer. Onus of disproving is upon the policyholder, if alive, or beneficiaries. Annexure - (II) 06. Life insurance Policy can be called in question within 3 years on the ground that any statement of or suppression of a fact material to expectancy of life of the insured was incorrectly made in the proposal or other document basis which policy was issued or revived or rider issued. For this, the insurer should communicate in writing to the insured or legal representative or nominee or assignees of insured, as applicable, mentioning the ground and materials on which decision to repudiate the policy of life insurance is based. 07. In case repudiation is on ground of mis-statement and not on fraud, the premium collected on policy till the date of repudiation shall be paid to the insured or legal representative or nominee or assignees of insured, within a period of 90 days from the date of repudiation. 08. Fact shall not be considered material unless it has a direct bearing on the risk undertaken by the insurer. The onus is on insurer to show that if the insurer had been aware of the said fact, no life insurance policy would have been issued to the insured. 09. The insurer can call 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 of age of life insured. So, this Section will not be applicable for questioning age or adjustment based on proof of age submitted subsequently. [Disclaimer: This is not a comprehensive list of amendments. Policy Holders are advised to refer to Insurance Act, 1938 as amended from time to time for complete and accurate details.] Exide Life Insurance Company Limited is a wholly owned subsidiary of Exide Industries Limited. The trademark Exide is owned by Exide Industries Limited and licensed to Exide Life Insurance vide Trademark license agreement dated 30th October 2014. Exide Life Insurance Company Limited. IRDAI Registration number:114, CIN: U66010KA2000PLC028273, Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No. 3/1, Millers Road, Bengaluru - 560 001. Toll Free: 1800 419 8228; Visit:exidelife.in. IRDAI Notice: Beware of spurious phone calls and fictitious/fraudulent offers. IRDAI clarifies to public that IRDAI or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call, number. Page 5 of 6
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