SBI Life Insurance Co.

Ltd
Corporate Office: 'Natraj', M.V.Road and Western Express Highway Junction, Andheri (East), Mumbai - 400069
IRDAI Registration No. 111 | Website: www.sbilife.co.in | Email: info@sbilife.co.in | CIN: L99999MH2000PLC129113
Toll Free: 1800 267 9090 (Between 9.00 am & 9.00 pm)

Customer’s Declaration:
Assessment of Suitability and Appropriateness for Sale of Third Party Products

I. Income (Gross - Mandatory deduction) + Other income Rs.600000

as declared by proposer / investor

II. Accumulated Savings (STDR/TDR/RD/CASA Balance) Rs.500000

III. Gross Annual Expenditure (Rs.) Rs.50000

IV. Occupation Organised Pvt. sector, Govt.

service, PSU

V. Date of Birth 22-09-2000

VI. Qualification Graduate

VII. Existing Ownership / Investments Insurance / MF Product :>5 yrs

Customer's Declaration:
I express my willingness to buy the SBI Life -Smart Swadhan Plus and declare that the above information are
provided voluntarily and confirm that the personal financial details submitted to the Bank are true & correct to the
best of my knowledge.
(Signature of the customer) This document is eSigned by Proposer.
Name: Mr. AKASH MEHER
Account No.: 38045248803
Mobile No.: 9861234458
Email ID:
Date: 7-9-2023

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 SBI Life Insurance Co. Ltd
Registered & Corporate Office: 'Natraj', M.V.Road and Western Express Highway Junction, Andheri (East), Mumbai - 400069
IRDAI Registration No. 111 | Website: www.sbilife.co.in | Email: info@sbilife.co.in | CIN: L99999MH2000PLC129113
Toll Free: 1800 267 9090 (Between 9.00 am & 9.00 pm)

Benefit Illustration(BI): SBI Life - Smart Swadhan Plus (UIN : 111N104V02)

An Individual, Non-linked, Non-Participating, Life Insurance Savings Product with Return of Premium

Proposal No OL1Z00099181310907092023055742

Channel / Intermediary Corporate Agents

Introduction

The main objective of the illustration is that the client is able to appreciate the features of the product and the flow of benefits in different
circumstances with some level of quantification. For further information on the product and its benefits, please refer to the sales brochure and/or
policy document.

Proposer and Life Assured Details

Name of the Prospect/Policyholder Mr. AKASH MEHER Name of the Life Assured Mr. AKASH MEHER

Age (Years) 22 Years Age (Years) 22 Years

Gender Male Gender Male

Premium Payment Option Limited Premium Payment Staff No

Term (LPPT)

State

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy.

Policy Details

Policy Option Not Applicable Amount of Installment Premium 19241.5

(Rs.)

Policy Term (Years) 10 Sum Assured (Rs.) 14,50,000

Premium Payment Term (Years) 5 Sum Assured on Death (at 14,50,000

inception of the policy) (Rs.)

Mode / Frequency of Premium Yearly Rate of Applicable Taxes 4.5% in the 1st policy year and
Payment 2.25% from 2nd policy year
onwards

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 Premium Summary

Base Plan Riders Total Installment Premium

Installment Premium without 19241.5 Not Applicable 19242

Applicable Taxes (Rs.)

Installment Premium with 1st Year 20107.37 Not Applicable 20,108

Applicable Taxes (Rs.)

Installment Premium with 19674.43 Not Applicable 19675

Applicable Taxes 2nd Year
onwards (Rs.)

Please Note

1. The premiums can be also paid by giving standing instruction to your bank or you can pay through your credit card.

2. Applicable Taxes (including surcharge/cess etc), at the rate notified by the Central Government/ State Government / Union Territories of India from
time to time and as per the provisions of the prevalent tax laws will be payable on premium as per the product features.

Benefit Illustration for SBI Life - Smart Swadhan Plus

policy Year Annualized Guaranteed Non- Guaranteed

premium
Survival Benefits / Other Benefits, if Maturity Benefit Death benefit Minimum Special Surrender
Loyalty Additions any Guaranteed Value
Surrender Value

1 19,242 0 0 0 14,50,000 0 0

2 19,242 0 0 0 14,50,000 11,545 20,012

3 19,242 0 0 0 14,50,000 20,204 33,481

4 19,242 0 0 0 14,50,000 38,484 50,029

5 19,242 0 0 0 14,50,000 48,105 68,309

6 0 0 0 0 14,50,000 48,105 72,158

7 0 0 0 0 14,50,000 48,105 76,968

8 0 0 0 0 14,50,000 67,347 80,816

9 0 0 0 0 14,50,000 86,589 85,627

10 0 0 0 96,210 14,50,000 86,589 90,437

Notes

1. Annualized premium shall be the premium amount payable in a year chosen by the policyholder, excluding the taxes, underwriting extra premiums
and loading for modal premiums, if any / Single premium shall be the premium amount payable in lumpsum at inception of the policy as chosen by
the policyholder, excluding the taxes and underwriting extra premiums, if any. Refer sales literature for explanation of terms used in this illustration.

2. All Benefit amount are derived on the assumption that the policies are 'in-force'

Important:

You may receive a welcome call from our representative to confirm your proposal details like Date of Birth,Nominee Name,Address,Email Id,Sum
Assured,Premium amount,Premium Payment Term etc.

You may have to undergo Medical tests based on our underwriting requirements.

I, Mr. AKASH MEHER having received the information with respect to the above, have understood the above statement before entering
into the contract.

Place :BALANGIR

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Date :7-9-2023

This document is eSigned by Mr. AKASH MEHER

Marketing official's Signature & Company Seal

I, Sibun Kumar Sahu have explained the premiums and benefits under the product fully to the prospect/policyholder.

Place :BALANGIR Date :7-9-2023 (CIF code- 991813109)

Name of CIF- Sibun Kumar Sahu
Authenticated by Id & Password

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 Proposal Number 1ZYG598666

Foreign Account Tax Compliance Act (FATCA)/ Common Reporting Standard(CRS)/ C-KYC
Declaration Form – For Individual only (including sole proprietors)

(Please consult your professional tax advisor for further guidance on your tax residency, if required)

Registered & Corporate Office: SBI Life Insurance Co. Ltd, Natraj, M.V. Road & Western Express Highway
Junction, Andheri (East), Mumbai - 400 069.IRDAI Registration no. 111.
website: www.sbilife.co.in | Email: info@sbilife.co.in | CIN: L99999MH2000PLC129113 | Toll Free: 1800 267 9090
(Between 9:00 AM & 9:00 PM).
Trade logo displayed above belongs to State Bank of India and is used by SBI Life under license.

Proposal No. 1ZYG598666

Proposer/Accountholder Name* Mr. AKASH MEHER

(* In case of joint name, declaration to be provided by both the proposers. An accountholder is person who is entitled to
receive the cash value or change the beneficiary of the contract)

Mother's Name Mrs LAXMI MEHER

Spouse's Name NA

Residential Status Resident Indian

C-KYC number 30028752580606

Country of Birth India Place of Birth BOLANGIR

GSTIN

Identification Aadhar Card Identification No XXXXXXXX07 Expiry Date NA

Proof 71

Address Proof AADHAAR Card No

In case you have selected “Service” as your occupation, Government Sector

please specify the nature of your Organization

Are you a tax resident of any country other than India? No

SI No Country/(ies) of Tax residency# Tax Identification number(TIN)/Functional Identification Type (TIN or other%,please
equivalent number% specify)

1 NA NA NA

2 NA NA NA

#To also include United States of America(USA), where the individual is a citizen/ green card holder of USA. %In case such number is not available,Kindly provide an explanation and attach it
to this form.

SI No Residence address/(es) for Tax Address Type Country code Telephone/ Mobile No
purposes

1 NA NA NA NA

2 NA NA NA NA

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 Proposal Number 1ZYG598666

Certification - Under penalty of perjury, I certify that

• I am aware that Central Board of Direct Taxes (“CBDT”) has notified Rules 114F to 114H as part of the Income-tax
Rules, 1962, (read alongwith FATCA/CRS instructions given below) which require Indian financial institutions such as
SBI Life to seek additional personal, tax and beneficial owner information and certain certifications and documentation
from all our proposers/ accountholders.
• I understand that SBI Life is relying on information provided in this form for the purpose of determining the status of the
accountholder in compliance with FATCA/CRS. SBI Life is not able to offer any tax advice on FATCA or CRS or its
impact on me.
• I acknowledge my responsibility to seek advice from professional tax advisor for any tax questions.I agree to submit a
new form within 30 days if any information or certification on this form changes or becomes incorrect.
• I agree that as may be required by domestic regulators/tax authorities, SBI Life may be required to report, reportable
details to CBDT or other authorities/agencies or may be required to provide informations to any institutions such as
withholding agents for the purpose of ensuring appropriate withholding from the policy/(ies) or any proceeds in relation
thereto or even close or suspend my policy/(ies), as appropriate.
•I hereby declare that the details furnished in the proposal no. specified above and in this declaration are true and correct to
the best of my knowledge and belief and I undertake to inform SBI Life of any changes there in, immediately. In case any
of information furnished in the proposal no. specified above and in this declaration is found to be false or untrue or
misleading or misrepresenting, I am aware that I may be liable.
•I hereby authorize SBI Life to consider details furnished in the proposal no. specified above and in this declaration for the
purpose of Central KYC Registry and to provide my details to CERSAI in the prescribed format. I further hereby consent
to receiving information from Central KYC Registry through SMS/Email or registered mobile number/email address
mentioned in the proposal no. specified above.
•I hereby authorize the Company to provide my/our details to banks, financial institutions and third party service providers
that the Company may have tie-ups with, for verification of proposal details and for servicing of resulting policy/(ies).

Signature of the Proposer

This document is eSigned by Mr. AKASH MEHER

Place :BALANGIR Date :07-09-2023

FATCA/CRS Instructions

In case Proposer/Accountholder has the following Indicia pertaining to a foreign country and yet declares self to be non-
tax resident in the respective country,Proposer/Accountholder to provide relevant Curing Documents as mentioned below:

FATCA/ CRS Indicia observed (ticked) Documentation required for Cure of FATCA/ CRS indicia/n(If Proposer/Accountholder
does not agree to be Specified USA person/ reportable person status)

a) United States of America (“USA”) place of birth 1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA;
2. Non-USA passport or any non-USA government issued document evidencing nationality or
citizenship (refer list below); AND
3. Any one of the following documents:
a. Certified Copy of “Certificate of Loss of Nationality or
b. Reasonable explanation of why the Proposer/Accountholder does not have such a certificate

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 Proposal Number 1ZYG598666

despite renouncing USA citizenship; or Reason the Proposer/Accountholder did not obtain USA
citizenship at birth

b) Residence/mailing address in a country other than India 1. Self-certification (as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes ofUSA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)

c) Telephone number in a country other than India (and no telephone number in India provided) 1. Self-certification ( as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)

d) Standing instructions to transfer funds to an account maintained in a country other than India 1. Self-certification ( as stated above) that the Proposer/Accountholder is neither a citizen of USA
nor a resident for tax purposes of USA or any other foreign jurisdiction; AND
2. Documentary evidence (refer list below)

List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body**
2. Valid identification issued by an authorized government body**(e.g.Passport,National Identity card, etc.)
**Government/ agency thereof or a municipality of the country or territory inwhich the Proposer/Accountholder claims to
be a resident.

FATCA-CRS.ver 06-06-19 ADD ENG 3

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 Proposal Number 1ZYG598666

Proposal Number 1ZYG598666 Proposer Name Mr. AKASH MEHER

Aadhaar Consent Form

I, Mr. AKASH MEHER, hereby give my voluntary consent to SBI Life Insurance Company Limited (SBI Life) and
authorize the Company to obtain necessary details like Name, DOB, Address, Mobile Number, email, Photograph through
the copy of Aadhaar card / QR code available on my Aadhaar card / XML File shared using the offline verification process
of UIDAI or Aadhaar Number/Virtual ID, Name, Date of Birth, Fingerprint/Iris and my Aadhaar details used for
authentication either through Yes/No authentication facility or e-KYC facility in accordance with the Aadhaar (Target
Delivery of Financial and Other Subsidies, Benefits and Services) Act, 2016 and all other applicable laws/ regulations. I
understand and agree that this information will be exclusively used by SBI Life only for the KYC purpose and for all
service aspects related to my policy/ ies, wherever KYC requirements have to be complied with, right from issue of
policies after acceptance of risk under my proposals for life insurance, various payments that many have to be made under
the policies, various contingencies where the KYC information is mandatory, till the contract is terminated. I have duly
been made aware that I can also use alternative KYC documents like Passport, Voter’s ID Card, Driving licence, NREGA
job card, letter from National Population Register, in lieu of Aadhaar for the purpose of completing my KYC formalities. I
understand and agree that the details so obtained shall be stored with SBI Life and be shared solely for the purpose of
issuing insurance policy to me and for servicing them. Further I understand, my biometrics will not be stored/shared by
SBI Life. I will not hold SBI Life or any of its authorized officials responsible in case of any incorrect information
provided by me. I further authorize SBI Life that it may use my mobile number for sending SMS alerts to me regarding
various servicing and other matters related to my policy/ies.

Place BALANGIR

Date 07-09-2023

4
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 Unique Reference No./Proposal No. 1ZYG598666

KEY FEATURES DOCUMENT

SBI Life - Smart Swadhan Plus (UIN: 111N104V02) offers you life cover and other benefits as stated in the
policy.

Underwriting shall be as per the “Board approved underwriting policy”

1 Aim of policy SBI Life - Smart Swadhan Plus (UIN: 111N104V02), an individual, non-linked, nonparticipating life
insurance savings product with return of premium which helps to meet
your insurance needs, with the added advantage of getting your total premiums paid^
back on Maturity, provided the policy is in-force.
^ The total premiums paid means total of all the premiums received, excluding any extra
premium and applicable taxes.

2 Benefits of the policy Death Benefit: Sum Assured on Death will be payable as a lump sum to the nominee or legal heir of the
life assured.
Sum Assured on Death:
For Single Premium (SP) Policies:
Higher of (Basic Sum Assured# or 125% of Single Premium)

For Limited Premium Payment Term (LPPT) / Regular Premium (RP) Policies:
Higher of (Basic Sum Assured# or 10 times of Annualized Premium* or 105% of the total premiums
received upto the date of death)

There is no waiting period under the product. The Death Benefit would be same (as defined above)
throughout the policy term

# Basic Sum Assured is the absolute amount of benefit chosen by the policyholder at the inception
of the policy.
*Annualized Premium is the premium amount payable in a year chosen by the policyholder,
excluding the applicable taxes, underwriting extra premiums and loadings for modal premiums, if any.

Maturity Benefit: On survival of the Life Assured up to maturity, 100% of the total premiums paid
during the policy tenure, shall be paid in a lump sum.

3 Policy Surrender The Single Premium policy can be surrendered at any time during the policy term.
For Limited Premium Payment Term (LPPT) / Regular Premium (RP) Policies: The policy will acquire
surrender value only if premiums have been paid for at least 2 consecutive years. The amount of
surrender value is Guaranteed Surrender Value (GSV) or Special Surrender Value (SSV), whichever is
higher.

4 Paid-Up Value For Limited Premium Payment Term (LPPT) / Regular Premium (RP) Policies:
If the policy has acquired surrender value and no further premiums are paid then it can
be converted to a paid up policy.
Please refer to the Sales literature for the benefits payable under Paid up policy

5 Loans on the Policy Loan facility is not available.

6 Exclusions Suicide: In case of death due to suicide, within 12 months from the date of commencement of risk under
the policy or from the date of revival of the policy, as applicable, the nominee or beneficiary of the
policyholder shall be entitled to at least 80% of the total premiums paid till the date of death or the
surrender value available as on the date of death whichever is higher, provided the policy is inforce

7 Grace period For Limited Premium Payment Term (LPPT) / Regular Premium (RP) Policies: 30
days from the premium due date for yearly/half yearly/ quarterly premium
frequencies and 15 days for monthly premium frequency.

8 Revival For Limited Premium Payment Term (LPPT) / Regular Premium (RP) Policies:
If premiums are not paid within the grace period and the policy is not surrendered, the
policy may be revived for full benefits within the revival period of five years from the date
of the first unpaid premium, only during the policy term.
The revival will be effected as per the Company’s Board approved underwriting policy.

9 Free look provision You can review the terms and conditions of policy, within 15 days for policies other than electronic
policies and policies sourced through any channel other than Distance Marketing and within 30 days for
electronic policies and policies sourced through Distance Marketing Channel, from the date of the
receipt of the policy document and if you disagree with any of those terms and conditions; you have the

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 Unique Reference No./Proposal No. 1ZYG598666

option to return the policy stating the reasons for your objection

10 Tax You may be eligible for Income Tax benefits/exemptions as per the applicable income tax laws in India,
which are subject to change from time to time. You may visit our website for further details. Please
consult your tax advisor for details.

11 Claim The details are mentioned in the Policy Document or you may contact the Company or your advisor or
bank branch, for further details.

Note: This document contains brief information about the key features of the Product. The same shall not be construed as terms and conditions
of the Policy or part thereof. For detailed terms and conditions governing the Policy, please read all parts of the Policy document. In case of any
conflict between the information given in the Key Features Document and the terms and conditions of the policy document, the terms and
conditions of the Policy Document shall prevail.

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SBI LIFE INSURANCE COMPANY LIMITED

COMMON PROPOSAL FORM
Registered & Corporate Office: Natraj, M. V. Road, & Western Express Highway Junction, Andheri (East), Mumbai - 400 069.
IRDAI Registration No. 111
Toll Free: 1800 267 9090(Between 9:00 AM & 9:00 PM) | Email: info@sbilife.co.in | Website: www.sbilife.co.in | CIN:
L99999MH2000PLC129113
SBI Life Insurance Co. Ltd. referred to as “SBI Life” or “ The Company”

"IN CASE OF UNIT LINKED LIFE INSURANCE POLICIES THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY
THE POLICYHOLDER"

SECTION ‘A’ PERSONAL DETAILS

Proposer (if different from Life Assured) / Life Assured / HUF Karta

First Name Mr. AKASH

Middle Name NA

Last Name MEHER

Gender Male Date of Birth 22-09-2000 Age 22 Years

Marital Status Married

Father's Name Mr SUDAM MEHER

Mother’s Name Mrs LAXMI MEHER

Spouse’s Name NA

C-KYC No. 30028752580606

PAN Card No. FQRPM9090J Form 60 NA

Age Proof Aadhar card with complete DOB KYC OVD (Officially Valid AADHAAR Card No
Document)

Identification Number XXXXXXXX0771

Resident Status Resident Indian

Nationality Indian Current Country of Residence India

Mobile Number 9861234458 Email Id

I hereby authorize SBI LIFE to send, any information/communication relating to this proposal/or the resulting policy through SMS /Email /Phone
/Letter /WhatsApp /any other electronic mode of communication to my registered email id/mobile number.

Qualification Graduate

CONTACT DETAILS

Address 1 S/O, S O SUDAM MEHER TEBADAMUNDA TEBADAMUNDA

TEBAD AMUNDA TEBADAMUNDA BOLANGIR-BOLANGIR,
767030, ODISHA, India

Communication address if different from above? (If Yes, then the No

following to be filled)

Communication Address (Address 2) S/O, S O SUDAM MEHER TEBADAMUNDA TEBADAMUNDA

TEBAD, AMUNDA TEBADAMUNDA, BOLANGIR-BOLANGIR,
767030, ODISHA India

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Occupation Details

Service

Force Name NA

Employee / Force No NA

Designation NA

Current place of posting(City and State) NA

For Defence personnel- Are you currently engaged or trained for future NA
involvement in any of the following?

Name of Employer / Workplace INDIA POST TUSRA

Specify the exact designation Post Master

Length of Service (Years) 10

Annual Total Income Rs. 600000

Are you exposed to any special hazard No If Yes, please provide details NA
associated with your occupation which may
render you susceptible to injuries or illnesses?
(e.g. chemical factory, mines, explosives,
corrosives, combative duties, oil exploration,
high sea voyage etc.)

Are you a “Politically Exposed Person” (PEP) No If Yes, please provide details NA
or a close relative of PEP?
“Politically Exposed Persons” PEPs are
individuals who are or have been entrusted with
prominent public functions in a foreign country,
e.g., Heads of States/Governments, senior
politicians, senior government/judicial/military
officers, senior executives of state-owned
corporations, important political party officials,
etc.
If No, in case your PEP status changes in
future, you shall inform SBI Life Insurance Co.
Ltd. of such a change.

Do you have any Criminal proceedings initiated No If Yes,please provide details NA

against you?

If previous question is yes then, Do you have NA If Yes,please provide details NA

any history of conviction under any criminal
proceedings in India or abroad?

e-INSURANCE ACCOUNT DETAILS

I want to receive the Insurance policy and all the information related to the proposed insurance Yes
policy through insurance repository.

Do you have e-Insurance account? No

If Yes, provide e-Insurance Account NA Repository Name NA

Number

• If No : Request to select any one insurance repository from below options:Repository Name : NSDL Database Management Ltd

NOMINEE DETAILS (Not applicable for Minor Life Assured / HUF Member)

S.No Name Date of Birth Gender Relationship with Life Percentage Share (%)* Address same as Life
Assured Assured’s Address
(Yes/No) If No, then
please provide

1 Mrs.LAXMI MEHER 01-07-1979 Female Mother 100 S/O, S O SUDAM

MEHER
TEBADAMUNDA
TEBADAMUNDA
TEBAD, AMUNDA
TEBADAMUNDA,
BOLANGIR-
BOLANGIR, 767030,

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ODISHA ,India

*Percentage share total should be 100%

APPOINTEE DETAILS :(Applicable in case nominee is Minor)

S.No Name Date of Birth Gender Relationship with Life Relationship with Signature/ Consent of
Assured Nominee Appointee

1 NA NA NA NA NA NA

SECTION ‘B-2’ PRODUCT DETAILS

Product Code 1Z Product Name SBI Life-Smart Swadhan Plus

Do you want to apply for Whole No Smoking Status NA

Life cover
In case Whole Life cover is
chosen, maximum maturity age is
100 years (last birthday of the life
assured). Applicable for SBI Life –
Shubh Nivesh (035) & SBI Life –
eShield Next (2N)

Plan Type Limited Premium Plan Option NA

Premium Frequency Yearly

(For Monthly mode, advance premium may be required, as mentioned in
the Benefit Illustration)

Are you or your No If Yes please state: NA Spouse :PF/Pension NA

spouse Self :PF/Pension Index/ Employee No.
working/retired from Index/ Employee No.
State Bank Group?(If
yes, please state name
of employer)

B 2 : Cover Details

Plan/Rider/option Policy Term(Yrs) Premium Payment Term(Yrs) Sum Assured(Rs) Premium Payable(Rs)

SBI Life-Smart Swadhan Plus 10 5 1450000 19242

Modal Premium Payable(Rs.) 19242

Applicable Tax Amount(Rs.)* 866

Backdating Interest, if any (Rs.) 0

Total Installment Premium 20108

Payable(Rs.)

* Taxes shall be applicable as mandated by Government of India from time to time.

BackDating : Upto a date within the same financial year in which the policy has been taken.
Do you wish to Backdate the policy? No If Yes, provide the Backdating Date NA

SELECT - PRODUCTS/ STRATEGY/ PLAN OPTION, (if any)

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Maturity/ Annuity/ Any other NA Maturity/ Annuity/ Any other NA

option* option Frequency*

* Mandatory for Pension Products

SECTION ‘C-2a’ HEALTH AND OTHER DETAILS OF LIFE ASSURED:

Do you have any other individual existing life insurance policy (from SBI Life or any other No
life insurer) or have you applied for any cover other than this SBI Life proposal? If Yes,
please provide details below

Name of Insurance Co. Yearly Premium(Rs) Sum Assured(Rs) Self/Spouse/Parent(pls. Specify) Policy Status

NA NA NA NA NA

Has any of your proposals for No If Yes, then provide the details NA
life/health/accident insurance ever
been declined /rejected, postponed,
withdrawn, or accepted with extra
premium?

No. Health Details of Life Assured Yes(Y)/No(N)

1 Height 5Feet 8inches Weight 68 Kgs Have you lost No
weight of 5Kgs or
more in last 6
months

2. Have you ever been treated, hospitalized, investigated or diagnosed or operated for any of the following (including but not limited to the specific
conditions mentioned under each category).Every point should be answered in “yes” or “no”

a. Diabetes Mellitus/ High Blood No b. Heart Disease of any kind : No

Sugar, High/Low Blood Pressure Chest pain, Angina, Coronary
or High Cholesterol Artery Disease, heart attack, valve
disorder, Rheumatic heart disease,
conduction problem, or any other
disease of Heart, or undergone
Angiography, Bypass, PTCA,
Pacemaker implant etc

c. Lung /Respiratory disorder of No d. Cancer/ Malignancy diagnosed No

any nature: Asthma, COPD, or suspected: Cancer, Overgrowth,
Tuberculosis (TB), Pneumonia, Cyst, Tumor, Malignant growth ,
Bronchitis, emphysema, or any Leukemia, enlarged lymph node,
other chest or lung disease etc Lymphoma, or undergone
Chemotherapy, radiotherapy,
FNAC, Biopsy, Scan etc

e. Kidney, Prostate or No f. Disorder of Liver or other No

genitourinary Diseases : Kidney digestive organs : Alcoholic and
failure, infection, Stone, Other Liver disease, Jaundice,
Obstruction, or any other disease, Hepatitis of any type, Liver failure,
Dialysis, Transplantation or infection, enlargement, Cirrhosis,
removal of kidney , Blood in urine, Ascites etc or Gastric
or enlarge prostate, adrenal gland ulcer/bleeding, vomiting of blood,
disorder etc blood in stools, Piles, hernia,
colitis, etc or any disease of
Esophagus, Pancreas, Gall bladder,
Spleen, Intestine, Rectum or any
digestive system or undergone
endoscopy, colonoscopy etc

g. Joints & Bone disorder, Vision No h. Brain or Spinal cord: Disorder No

or Hearing disorder, Deformity, of brain and/or spinal cord or
loss of organ or any congenital Nervous system, Hemorrhage,
defect: Arthritis (rheumatoid, bleeding, Tumor, stroke, paralysis,
ankylosing, Osteomyelitis), gout, TIA, epilepsy/fits, seizures, coma,
deformity /disability, polio, any head injury, fainting loss of
disease of bone, joints, muscles, consciousness, tremors, impaired
spine , vertebral disc or, disorders movement of limbs, incontinence,
of eyes, ear, nose, throat, or or any other disorder of nerves or
amputation, absence or had MRI, CT scan etc
transplantation of organs etc

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i. Psychiatric disorder: Mental No j. HIV or STD: Were you or your No

illness including, anxiety, spouse/partner test positive for
depression, schizophrenia, stress, HIV/AIDS or any other Sexually
Nervous breakdown, attempted Transmitted Disease?
suicide etc

k. Blood or hormonal No l. Current/ past general medical No

disorder(Thyroid etc) & others: condition Do you have any or in
Anemia, Bleeding or clotting last 5 years any, medical condition,
disorders, Autoimmune Disorder, symptoms , test results or
SLE, Lupus, thyroid disorder, procedure not asked above for
goiter, pituitary hormones disorder which you were/are under
etc treatment, observation or being
Hospitalized for more than 5 days
or were absent from work
continuously for more than 5
days, (excluding, common cold,
fever) or are you currently under
any medication?

o. Questions For Female Lives

1) Are you currently pregnant? NA If YES, kindly state expected NA

delivery date

2) Have you ever consulted a doctor because of an irregularity at the breast, vagina, uterus, ovary, NA
fallopian tubes, menstruation, complications during pregnancy or child delivery or undergone any
gynecological investigations for illness, internal checkups, breast checks such as smear Test,
mammogram or biopsy etc

If any of the above questions is ticked "Yes" (1 -2) then provide details in the below table. Also provide all related reports

Name of the disease/ disability/ deformity/ Date of Diagnosis Since when Currently under treatment / Recovered Date of hospitalisation/surgery done or if
procedure DD/MM/YYYY planned

NA NA NA NA

3. Are any of your family members (include parents, brothers, sisters, spouse and No
children) suffering from/have suffered from/have died of heart disease, high blood
pressure, diabetes, stroke, cancer, kidney disease or any other hereditary/familial
disorder, before 55 years of age? If yes, please share details in the table below

Relation Alive(Yes/ No) Current Age/Age at Death Specify Nature of disorder

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

NA NA NA NA

4. Do you currently or have you in the past Smoked, Consumed Tobacco, No

Alcohol, any Narcotic or have ever been treated for complications arising
due to them?
If currently pursuing habit If Quitted
Habit Type Quantity Consuming since how long? Since how long? Consumed how long?
(Number of Years) (Number of Years) (Number of Years)
Smoking NA NA NA NA NA
Tobacco NA NA NA NA NA
Chewing

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Alcohol NA NA NA NA NA
Narcotic NA NA NA NA NA

5. Do you take part in or do you No If Yes, please specify NA

have any intention of taking part in
any hazardous sports, hobbies,
activities or pursuits (e.g.
mountaineering, diving, racing or
aviation other than as a fare paying
passenger) that could be dangerous
in any way?

SECTION ‘C-2b’ Additional Questions For Female Lives

1. Husband's Annual Income (Rs) NA

2. Husband's Insurance Details
Name of Insurance Co. Yearly Premium(Rs) Sum Assured(Rs) Policy status

NA NA NA NA

SECTION ‘D’ CHANNEL DETAILS(For office use - to be filled by Sales Representative)

Channel Name Corporate Agency(SBG)

Is this Proposal sourced through No If Yes, please state the Distance NA

Distance Marketing? Marketing Mode

CIF Code 991813109 CIF Name Sibun Kumar Sahu

Bank/Broker/CA/IMF Code 00 Bank/Broker/CA/IMF Name STATE BANK OF INDIA

Worksite Code NA

Sourcing Branch Code 2133 Sourcing Branch Name TUSRA

For Institutional Alliances / Corporate Agency(SBG) only

Code 1 NA Code 2 NA Code 3 NA

Code 4 NA Code 5 NA Code 6 NA

SECTION ‘E’ PREMIUM & BANK DETAILS

PREMIUM PAYMENT

GSTIN of policyholder NA

Is deposit for premium under this proposal paid by you Yes

If answer is No, please provide required information in the Proposal
Form

Source of premium funding Salary

Please note that SBI Life branches and its sales team are not authorised to collect cash from its customers

RENEWAL PREMIUM PAYMENT Auto Debit^

^Please fill the Auto Debit Mandate available at the end of the form for seamless payment of Renewal premium.

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BANK ACCOUNT DETAILS OF PROPOSER/LIFE ASSURED

Account Number 38045248803 Account Type Savings

Bank Name STATE BANK OF INDIA Bank Branch Name TUSRA

Name of Account Holder Mr AKASH MEHER

IFS Code SBIN0002133

Please submit any one of the below listed documents for direct credit of Copy of Bank Statement
any refunds / payouts if any, to this account.

I declare that the information given above is true and correct. I hereby authorize SBI Life to directly credit any payment/refund, if any, to the above
mentioned account.
Note: Please ensure that the Bank details provided are correct and complete. Please note that SBI Life shall not be responsible if any payments to the
Bank account number provided by you fail on the ground that the bank details provided are incorrect.
This document is eSigned by Mr. AKASH MEHER

SECTION ‘F’ Declarations by the Proposer /Life Assured /HUF Karta :

• I hereby declare that I have answered the questions in the Proposal Form after having fully understood the nature of the questions and importance of
disclosing all correct information. I further declare that the statements, answers and/or particulars given by me are true and complete in all respects to the
best of my knowledge and I have not concealed any material information which may affect the decision of SBI Life Insurance Company Ltd. (the
Company) to assess the risk. I understand that the information provided by me will form the basis of the insurance policy. All documents submitted by
me along with this Proposal Form are authentic, valid, and I declare that relevant true copies of originals for the purpose of this Proposal Form have been
submitted.
• I understand and agree that the statements in this proposal constitute warranties. If there is any mis-statement or suppression of material information or
if any untrue statements are contained therein or in case of fraud, the said contract shall be treated as void subject to the provisions of section 45 of the
Insurance Act, 1938, as amended from time to time.
• I declare that I have received and fully understood the Product Brochure and Benefit Illustration of the plan of insurance under which I have applied for
a Policy on the Life to be Assured. Further, I accept that the investment rates assumed under the Benefit Illustration are not guaranteed and the actual
benefits under the policy will vary from those shown in the Benefit Illustration.
• I agree that after the date of submission of this proposal but before the acceptance of risk or issue of the policy document by the Company (i) if there are
any adverse circumstances connected with my/our occupation, financial condition, health condition, or (ii) if a proposal for assurance on my life or on
the life to be assured made to any other insurance company has been withdrawn or dropped or accepted at an increased premium or on terms other than as
proposed by me, I shall forthwith intimate the same to the Company, in writing to reconsider the terms of acceptance of this proposal. Any omission on
my/our part to do so shall render the contract of assurance invalid. The Company reserves the right to accept, decline or offer alternate terms on my/our
proposal for Life/Health Insurance.
• I understand and agree that, the PROPOSAL WILL NOT BE CONSIDERED UNTIL THE FULL PREMIUM INCLUDING TAXES, IS PAID BY ME.
• I understand and agree that The risk cover under this proposal shall commence only after the risk under the Proposal Form is accepted by the Company
and such acceptance is communicated to me in writing by the Company. I agree that the amount held in proposal/policy deposit shall not earn any
interest except as may be provided in the relevant regulations.
• I hereby confirm that all premiums will be paid from my bonafide sources and in accordance with the provisions of the Prevention of Money
Laundering Act 2002 (as amended from time to time) or any other applicable laws.
• I also understand that I am liable to pay all the Applicable Taxes and/or any other statutory levy/duty/ surcharge, at the rate notified by the State
Government or Central Government of India from time to time, as per the applicable tax laws on premium and/or other charges (if any) as per the product
features.
• I hereby voluntarily give my consent to collect, process, receive, possess, store, deal or handle my/our sensitive personal data or information [as defined
in the Information Technology (Reasonable security practices and procedures and sensitive personal data or information) Rules 2011 as amended from
time to time], and share Data with third parties/ vendors associated with the Company for various purposes and outsourced activities exclusively related
to issuance/servicing/settlement of claim as required under the Policy.
• I agree and authorize(i) my past and present employers / business associates, any doctor/medical examiner / hospital / laboratory / clinic / insurance
company (notwithstanding any usage or custom or rules/ regulations of such hospital or laboratory or clinic) to disclose and furnish such documents
regarding my employment/business, my health and habits or health and habits of the Life to be Assured (without taking the prior consent of my family or
of any member thereof) to the Company as it may require either for the purpose of processing my proposal for insurance or at any time thereafter for any
other purpose in relation to the Policy that may be issued in pursuance of this proposal for insurance (ii) the Company may, without any reference to me
or my family or any member thereof, furnish any details/ information furnished in this Proposal Form to any judicial or statutory or other authority or to
any insurer or reinsurer in connection with the processing of this proposal for insurance or for the purpose of servicing and settlement of claims of

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resultant policy.
• I hereby authorize the Company to assess the health status and conduct screening / confirmation / telephonic verification/reconfirmation of the life/lives
to be assured including the health status through medical examinations which may include Laboratory tests, Cardiology, Radiological investigations and
other medical tests including blood tests to detect bacterial/viral/fungal infections if required by the Company. I/We hereby give my consent to undergo
HIV1/2 test. I am aware that this test is only for screening purpose and not confirmatory for HIV/AIDS.
• I understand and agree that the insurance contract will be governed by the provisions of the Insurance Act 1938,as amended from time to time,
Information Technology Act 2000, and the Indian Contract Act, 1872, as amended from time to time, and all other applicable statutes and prevailing laws
in India as amended from time to time.
• I hereby authorize the Company to provide/receive my details to/from banks, financial institutions, credit bureaus, insurance repository, third party
service providers that the Company may have tie-ups with and insurance intermediary for this proposal/resulting policy for verification of the details of
this proposal and for servicing my policies or settlement of claims.
• I / We hereby authorise the Bank or financial institution to provide copy of my/ our KYC documents available with them to the Company.
• I hereby authorize SBI Life to consider details furnished in the proposal number specified above and in this declaration for the purpose of Central KYC
Registry and to provide my details to CERSAI in the prescribed format. I hereby consent to receiving information from Central KYC Registry through
sms/ email on the above registered number/email address.
• I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any
changes in KYC related data therein, immediately. In case any of the information is found to be false or untrue or misleading or misrepresenting, I am
aware that I may be held liable for it.
• This consent shall hold good even if I register my number with the National Customer Preference Register (NCPR). I agree that the information
pertaining to my proposal or policy will be sent to the mobile number given in the proposal form or to the number subsequently changed by me.
• Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and/or employer
from divulging any knowledge or information about me concerning my health, employment on the grounds of secrecy, I, my heirs, executors,
administrator or any other person or persons having interest of any kind whatsoever in the life insurance cover provided to me, hereby agree that such
authority, having such knowledge or information, shall be at any time at liberty to divulge any such knowledge or information to the Company.
•I am aware that SBI Life-Smart Swadhan Plus is a Limited premium policy and I am aware that I would need to pay premium for 5 years (Premium
Payment Term) and have selected the product & the options applicable/available for me.
• I agree that by submitting this application, I will be bound by all the statements/disclosures of material facts made through the electronic process in the
same manner and to the same extent, as if I have signed and submitted the written proposal for insurance to the Company. I accept and agree to affix my
signature (in electronic mode/tablet/mobile) here.
• I agree to the above declaration.
Signature of the Proposer
This document is eSigned by Mr. AKASH
MEHER

Witness by (CIF code- 991813109)

Name of CIF- Sibun Kumar Sahu
Authenticated by Id & Password
Place :BALANGIR Date :07-09-2023

Prohibition of Rebates : Section 41 of the Insurance Act, 1938, as amended from time to time,states
No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out 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.

Non-Disclosure : Extract of Section 45, as amended from time to time,states

a). No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy. A policy of
life insurance may be called in question at anytime within three years from the date of the policy, on the ground of fraud or on the ground that any
statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document on the

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basis of which the policy was issued or revived or rider issued. The insurer shall have to communicate in writing to the insured or the legal representatives
or nominees or assignees of the insured, the grounds and materials on which such decision is based.
b). No insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement or suppression of a material
fact was true to the best of his knowledge and belief or that there was no deliberate intention to suppress the fact or that such mis-statement or suppression
are within the knowledge of the insurer.
In case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
c). In case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on the grounds of fraud, the premiums
collected on the policy till the date of repudiation shall be paid.
d). Nothing in this section shall prevent the insurer from calling 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 that the age of the life insured was incorrectly stated in the
proposal.
For complete details of the section and the definition of 'date of policy', please refer Section 45 of the Insurance Act 1938, as amended from time to time.

Place BALANGIR Date 07-09-2023

Section 41 and 45 have to be verified at your end from the Insurance Act, 1938, as amended from time to time.

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