CUSTOMER DECLARATION FORM & DIRECT DEBIT FORM

Online Proposal form ID / Application number _______________________________

TO BE FILLED BY THE CUSTOMER

I/We _______________________________________________request you to process the proposal with the above mentioned
application number submitted online/digitally on the company’s website www.bharti-axalife.com
Name of Insurance Plan _______________________________________________________________________________
The premium payable is ₹ ______________________ on a M Q HY Y frequency for a premium paying term of ___ years
& Sum Assured is ₹ _______________________________ From Agent Name & Code: _______________________________
Mobile No ______________________________ Email ID ___________________________________________________________
M - Monthly, Q - Quarterly, HY - Half Yearly, Y - Yearly
I/We understand that I/we may receive calls from Bharti AXA Life in relation to my application for insurance or the resulting policies. I/We give my consent to Bharti AXA Life to make such calls even
when I am/we are registered under NDNC category

DISCLAIMERS

I/We have received, read and fully understood the relevant documentation/information including the KEY feature document, Proposal Form
received from ___________________________@bharti-axalife.com and have understood and confirm to the product features and Illustration of
benefits and the information captured in the Proposal Form.

• 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 Bharti AXA Life. I declare that the content of the form
and document has been fully explained to me and I have fully understood the significance of the proposed contract. • I/We have submitted the proposal to buy this product on my/our accord after
having read and understood the terms and conditions of the said product on company’s website i.e. www.bharti-axalife.com. • I/We have verified the contents of the proposal form and understand and
agree that by submitting this proposal for Insurance through the company’s website, 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 had signed and submitted a written proposal for insurance after having read and understood the illustrations of benefits. • I/We fully understand the nature of the questions including health
related questions and the importance of disclosing all material information to the company while answering such questions in the proposal duly filled in online/digital by me or as per the information
provided by me. • I/We declare that answers given by me/us to all questions in the online proposal including the information given to the company as to the state of health & habits of the life/lives to
be insured are true and complete in every respect. • I/We undertake to notify the company forthwith, in writing of any changes in my/our health, occupational and financial state between the date of
this proposal and the date of the acceptance of the risk by the company. • I/We understand that any misstatement, suppression or non-disclosure of material information by me/us or where the
company is not notified of any change as mentioned above, the company shall have the right to cancel the policy or to repudiate the claim or to declare the policy void in accordance with Section 45 of
the Insurance Act and amount, if any, shall be refunded to the customer based on the policy terms and condition. I/We understand and confirm that the company shall have the sole and absolute
discretion to accept, decline or offer alternate terms on this proposal for life insurance. • I/We hereby declare and confirm that I/we am/are making the premium payment towards this proposal through
own bank account/credit card and I/we agree to submit a third party declaration in case the premium payment is not made from own account. • In case of premium payment through cash, I understand
and confirm that I will personally visit the branch office of the company for depositing the cash along with this Customer Declaration Form. • I/We further state and confirm that whatever is stated,
declared, confirmed or agreed above are done/effected on my/our own freewill and volition. • I consent agree and hereby state that I have no objection in authenticating myself with Aadhaar based
authentication system and UIDAI sharing of my Aadhaar details including name, father’s name, date of birth, address, mobile number, email id, gender and image for Aadhaar based validation/e-KYC
through biometric and/or One Time Pin (OTP) authentication for the purpose of availing Life Insurance Policy from Bharti AXA Life Insurance Co. Ltd. and servicing of said policy.

Ensure you know your policy details SIGNATURE OF PROPOSED POLICY HOLDER (if different)
SIGNATURE OF LIFE ASSURED

Name: ________________________________________________ Name: ________________________________________________

Date: ________________ Place: ___________________________ Date: ________________ Place: ___________________________

(This section needs to be filled only if ECS has been opted for)

Debit Mandate Form NACH/ECS/DIRECT DEBIT

UMRN Date
Sponsor Bank Code CITI000PIGW Utility Code CITI00002000000037
I/We hereby authorize BHARTI AXA LIFE INSURANCE CO. LTD. to debit (tick ) SB/CA/CC/SB - NRE/SB - NRO/Other

Bank A/C number

Tick ( )
CREATE with bank Name of customer’s bank IFSC or MICR
MODIFY an amount of Rupees Amounts in words `
CANCEL
FREQUENCY Monthly Qty H-Yrly Yrly As & when presented DEBIT TYPE Fixed Amount Maximum Amount
Policy No Phone No
Reference NOT APPLICABLE Email ID
I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges of the bank
PERIOD
From Signature of Primary Account Holder Signature of Account Holder Signature of Account Holder

To Name as in Bank Record Name as in Bank Record Name as in Bank Record

1. 2. 3.
Or Until Cancelled
•This is to confirm that the declaration has been carefully read, understood & made by me/us. I am authorizing the user entity/Corporate to debit my account, based on the instruction as agreed and signed by me.
•I have understood that I am authorized to cancel/amend this mandate by appropriately communicating the cancellation/amendment request to the user entity/Corporate of the bank where I have authorized the debit.

I wish to pay my premium to Bharti AXA Life Insurance Co. Ltd. through a debit to my account on of the calendar.
Debit date can be opted from 1st to 28th. Please note debit date is not available for 29th, 30th and 31st.

Please see overleaf for Terms & Conditions

 Application No ______________________
CONFIDENTIAL REPORT BY THE LICENSED SALES PERSON

1. How do you know the life to be Insured/Proposer_____________________________________________

2. If the life to be Insured/Proposer is immediate family* then please specify the relationship ________________________
3. If the life to be Insured/Proposer is MOA’s/MOM’s Immediate family, then please specify the relationship with
MOA/MOM ______________________________
4. How long have you known the life to be Insured/Proposer ____ Years ____ Months
5. Income details of proposer (per annum) Salary ______________ Business ______________ Agriculture _________________
Others ______________ Total __________________
6. Do you have any information of the life to be assured is having or suffered from any illness or surgery or undergone any operation
Or undergone any medical Investigation or is physically handicapped or mentally ill. Yes No
If reply to any of above is YES, please provide details ___________________________________________________________
7. Any other risk associated with occupation, sports, pursuit, financial/social position or personal habits of life to be Insured
that could affect the risk in the insurance proposal, please specify _______________________________________________
*Immediate family is spouse, parents, grandparents, grandchildren, siblings & their spouses.

DECLARATION: I, hereby declare that all information as provided in this proposal in connection with this proposal, pertaining to the medical, personal or financial standing of the proposer and having any material effect
on the acceptance of this proposal for insurance is true and complete to the best of my knowledge and belief. Should there be any adverse change in my opinion I shall inform the company of the same. I confirm that
I have verified the identity, current and permanent residential address of the proposer, the nature of his/her business and his/her financial status. Have verified the financial capacity of the proposer to determine that
the premium involved is within the proposer's financial capacity. I certify that I have explained the product brochure and the benefit illustrations to the Proposer and have made no statements which are inconsistent
with the same. I further declare that to the best of my knowledge the premium amounts are not sourced from proceeds of any criminal activities/offence listed in the Prevention of Money Laundering Act 2002. Should
there be any adverse change in my opinion of the integrity or reputation of the Proposer, I shall inform the Principal Compliance Officer of the company.

Financial/Advisor/Specified Person of Corporate Agent/Broker/Employee MOA’s/MOM’s/ Branch Sales Head/Senior Manager or above (Sales)

Code: _______________ Designation: ____________________ Code: _______________ Designation: ____________________

Name: ______________________________________________ Name: ______________________________________________

Signature: ___________________________________________ Signature: ___________________________________________

Date: DD MM YYYY Date: DD MM YYYY

BSM DECLARATION - NON MANDATORY

I confirm that I have met/spoken to the customer for the Life Insurance Proposal. I confirm that the customer is aware of all product features and
that the policy sold is in line with the customer’s requirements. The premium paying capacity of the said customer has been established. I have
also explained that there are no other benefits apart from the ones mentioned in policy terms & conditions.
I approve that the policy is Self-Policy and/or that is Splitting of Policy BSM Signature

Name ___________________________________________

Employee code _________________________ Branch _____________________

INSTRUCTIONS TO FILL NACH

1) UMRN is auto-generated during mandate creation and is mandatory to be updated
during amendment and cancellation of mandate. (Maximum length- 20 alphanumeric
characters).
2) Date in DD/MM/YYYY format.
3) Sponsor Bank IFSC/MICR code left padded with zeros where necessary. (Maximum
length- 11 alphanumeric characters).
4) Utility Code of the Service Provider. (Maximum length- 18 alphanumeric characters)
5) Name of Service Provider.
6) Tick on box to select type of action to be initiated.
7) Tick on box to select type of account to be effected.
8) Customer’s legal account number, left padded with zeros. (Maximum length- 35
alphanumeric characters)
9) Name of bank and branch.
10) IFSC/MICR code of customer bank. (Maximum length- 11 alphanumeric characters)
11) Amount payable for service or maximum amount per transaction that could be
processed, in words.
12) Amount in figures, similar to the amount mentioned in words. (Maximum length- 13
digit numeric, in paise)
13) Service Provider generated customer reference number.
14) Service Provider generated Scheme/Plan reference number.
15) Tick on box to select frequency of transaction.
16) Validity of mandate with date in DD/MM/YYYY format.
17) Names of customer/s and signatures as well as seal of company (Where required).
(Maximum length of name- 40 alphanumeric characters)
18) Undertaking by customer.
19) Permanent ID of customer e.g. PAN/Aadhar No
20) Telephone no with STD code of customer.
21) 10 digit mobile number of customer.
22) Mail ID of customer.
23) On the Policyholder electing the option/mode to pay the renewal premiums, the same,
unless revoked and/or modified by him/her subsequently by a 15 days prior written
notice to the company, shall be valid and binding on the Policyholder.
24) The Policyholder expressly understands and agrees that if two (2) successive
payments/instructions in case of monthly premium payment mode or any one (1)
payment/instruction in case of quarterly/half-yearly/yearly premium payment mode,
are not received/honored, the company reserves the right to automatically
cancel/withdraw the facility forthwith without notice.
25) In case of ULIP policies, payments made on a non-working day or a holiday, NAV (Net
Asset Value) applied would be of the next working day. However if the premium is
received in advance, the amount will be adjusted on due date and the NAV would be
applicable of due date.
26) I/We hereby authorize Bharti AXA Life Insurance Co. Ltd. to debit the revised premium
due, on account of change in service tax, education cess or any other charge levied, or
by way of any change exercised as per the policy features.

Registered office: Unit 601 & 602, 6th Floor, Raheja Titanium, Off Western Express Highway, Goregaon(E), Mumbai 400 063.
Email: service@bharti-axalife.com, visit us at: www.bharti-axalife.com IRDAI Regd. No: 130, Comp No: Dec-2017-2998, CIN: U66010MH2005PLC157108