MAX LIFE INSURANCE COMPANY LIMITED

Regd. Office : 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr, Punjab-
144533
Head Office: 11th & 12th Floor, DLF Square, Jacaranda Marg, DLF City Phase-II, Gurugram - Haryana,
122002.

NON LINKED PROPOSAL FORM PROPOSAL NUMBER: 164256083

GO/CA/Broker Code: QB017

Do you have a Max Life Insurance Policy or have currently applied simultaneous policies? If yes give Policy/Proposal number NO

Purpose of Insurance CHILDREN’S MARRIAGE/EDUCATION

I want to receive physical policy document- YES
Objective of Insurance INDIVIDUAL POLICY

Product Solution N/A Affinity Customer: N/A Existing Customer: NO

A. PERSONAL DETAILS
PROPOSER/JOINT LIFE LIFE TO BE INSURED(if other than proposer)
1. Title MS

First RADHIKA

2. Name Middle

Last PUJARI

First RAMESH
3. Father's / Husband
Name
Last PUJARI

4. Date of Birth 25-07-1990

5. Gender FEMALE
6. Nationality INDIAN
7. Marital Status WIDOW
8. Education PRIMARY SCHOOL
9. Relationship with Proposer/ Joint Life SELF

10. Industry Type OTHERS

11. Organisation Type PARTNER/PROP

12. Occupation/Job Title SELF EMPLOYED
13. Name of entity / employer
14. Annual Income (Rs) 600000

15. Is the Life to be Insured / Proposer / Joint Life / Nominee / Payor a Politically Exposed Person ? NO

16. NOMINEE DETAILS Nominee 1 (Mandatory) Nominee 2 (Optional) Nominee 3 (Optional)

a. Title MR NA NA

b. Name First POOJARI NA NA

Middle SRI NA NA

Last RAM NA NA

c. Date of Birth 03-04-2017 NA NA

d. Gender MALE NA NA
e. Percentage of Share 100 NA NA
f. Relationship with Proposer/ Joint
SON NA NA
Life
g. Appointee Full Name (If nominee
BALLE RAJAMMA NA NA
is under age 18)
h. Appointee relationship to
OTHERS NA NA
Nominee
i. Appointee Gender FEMALE NA NA
j. Appointee Date of Birth 01-01-1972 NA NA

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17. CURRENT RESIDENTIAL ADDRESS

House No./Apt. Name 3-16-104/30/A1,VENKAT REDDY NAGAR, RAMANTHAPUR

Society Road/Area/Sector VTC:AMBERPET, PO: AMBERPET

Landmark
Village/Town SUB DISTRICT: AMBERPET City/District HYDERABAD
Pin Code 500013 State/UT TELANGANA Country INDIA
Mobile Std
Mobile No. 1 7337426572 7337426572 Telephone#
No. 2 Code
E-mail ID radhikapujari5@gmail.com

18. PERMANENT RESIDENTIAL ADDRESS (optional)

House No./Apt. Name 3-16-104/30/A1,VENKAT REDDY NAGAR, RAMANTHAPUR

Society Road/Area/Sector VTC:AMBERPET, PO: AMBERPET
Landmark
Village/Town SUB DISTRICT: AMBERPET City/District HYDERABAD
Pin Code 500013 State/UT TELANGANA Country INDIA

19. Preferred Mailing Address Current Residential

20. Do you wish to hold for this policy electronically under e-Insurance ? NO

B. COVERAGE INFORMATION -Type of Coverage

Sum Premium
Premium Income Payout Coverage Modal
a. Base Plan Variant Assured/Income Payment GST
Back Option Frequency Term Premium
Payout Term
MAX LIFE SMART WEALTH SHORT TERM
NA 106695.0 ANNUAL 13 12 25375 1142.00
PLAN INCOME
Income
Income
Deferment Income Start Year Death Multiple
Period
Period

NA NA NA

Premium Back Sum Coverage Premium Payment Modal

b. Riders/Optional Benefits GST
Option Assured Term Term Premium
NA NA NA NA NA NA NA

Modal Premium without GST* and Cess 25375.00 GST* and Applicable Cess 1142 Total Premium Paid 26517

*GST shall comprise of CGST, SGST/UTGST or IGST (whichever is applicable) including cesses and levies, if any. All applicable taxes, cesses and levies, as per
prevailing laws, shall be borne by you.
c. Death Benefit Option NA d. Life Stage Benefit NA
e. Policy Continuance Benefit (PCB) NA f. Avail Income on a Special Date No
Bonus Option NA
(Not Applicable for plans that offer reversionary Bonus)

2. NEFT BANK A/C DETAILS OF All Payouts will be credited to this account through Electronic mode of payment. (This will be applicable at select
PROPOSER/ JOINT LIFE cities as per facilities/arrangements of Max Life Insurance).

MICR Code: 500015129 Bank Account Number: 8685101008436

IFSC Code: CNRB0013045 Account Holder's Name: PUJARI RADHIKA

Type of Bank Account: SAVINGS

Bank Name & Branch: CANARA BANK HYDERABAD
ACCOUNT

Banking Since: 21-06-2019

3. Permanent Account Number (PAN): EMFPP3115J Form 60 NO (for proposer/jointlife) Form 60 NA (for Insured)
TDS may be applicable, in accordance with Income Tax Act 1961, as amended from time to time.

4. Mode of Payment: SEMI-ANNUAL 5. Renewal premium by: ECS 6. Source of Funds BUSINESS

7. IS PAYOR DIFFERENT FROM THE PROPOSER ? NO

8. Are you a Max Life Agent Advisor or an employee of a Max group company/ Corporate Agents? NO
9. Effective Date of Coverage: 23-07-2024

10. Premium Payment Details

Amount in Words: TWENTY SIX THOUSAND FIVE HUNDRED SEVENTEEN

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 Paid Rs: 26517.00 Payment by ONLINE
Cheque / Draft No. / Instrument no ZAX62195976248 Date: 24-07-2024
Bank Name & Branch: NA

C. INFORMATION OF LIFE TO BE INSURED

Proposer/Joint Life to be
Life Insured

1. Do you have any life or Critical Illness insurance policy issued, pending approval from any other insurance companies or has
your application for Life/Health/Critical illness insurance or its reinstatement ever been offered at modified terms,rejected or NO NA
postponed ?

Proposer/Joint Life to be
Life Insured

2. In the next 12 months do you intend to travel or reside abroad other than on holiday of more than 4 weeks? NO NA

3. Do you participate or do you intend to participate in any hazardous activities as part of your Occupation/ Sports/ Hobby? NO NA

4. Have you ever been convicted or are you under investigation for any criminal charges ? NO NA

5. FOR FEMALE LIFE TO BE INSURED YES

Spouse Details: Occupation: NA Income: NA Insurance Amount: NA Are you pregnant? Yes No

If 'Yes', how many months? NA Do you have any complications related to pregnancy? If 'Yes' give details? NA

6. FOR MINOR LIFE TO BE INSURED (AGE < 18 YRS.) NO

D. MEDICAL INFORMATION
Proposer/Joint Life to be
1. FAMILY HISTORY
Life Insured

Has any two (2) or more of your family members (parents & Siblings) ever been diagnosed with diabetes or
NO
hypertension or kidney failure or cancer or heart Attack or any Hereditary Disorder before the age of 60 ?

2. Proposer/Joint Life Life To Be Insured

Height 149 cm NA
Weight 55 kg NA

3. Have you ever been investigated, treated or diagnosed with any of the following conditions. Proposer/Joint Life to be
If yes, please provide details Life Insured

i) Diabetes /High blood sugar levels NO NA

ii) Hypertension/ High Blood Pressure, High Cholesterol or Thyroid disorder NO NA

iii) Heart or vascular disorder including chest pain, stroke, heart attack or Angioplasty, CABG or any other heart
NO NA
surgery.

iv) Breathing or lung disorders including asthma, emphysema, tuberculosis. NO NA

v) Liver or digestive system related disorder including jaundice ,gall bladder, pancreas or Hepatitis B/C. NO NA

vi) Any abnormal growth like tumour,lump,cancer or blood disorder, including anemia or thalassaemia or Sexually
NO NA
transmitted disease ( STD ) including HIV or AIDS.

vii) Any kind of Kidney or bladder disorder, including kidney failure, renal stone, nephritis or prostrate disorder. NO NA

viii) Any neurological or mental health problem like paralysis, multiple sclerosis, Parkinson's, epilepsy, depression or
NO NA
anxiety.

ix) Muscular-skeletal or joint disorders, including any kind of arthritis, gout, osteoporosis. NO NA

x) Are you having history of any hospitalization, treatment or investigation? NO NA

xi) Have you advised now or in last 5 yrs tests like X-Ray/CT scan/MRI/ Ultrasonography/ ECG/Blood test or any other
NO NA
investigatory or diagnostic tests, or any type of surgery.

Xii) Have you ever been diagnosed with any form of internal or external congenital anomaly or defect i.e. any
NO NA
condition(s) which is present since birth, and which is abnormal with reference to form, structure or position?

Xiii) Have you had any genetic testing before? NO NA

Proposer/Joint Life to be
4. Tobacco/Alcohol/Drugs Consumption: Do you consume any of the following ?
Life Insured

i) Tobacco ( Smoking /Chewing) currently or even occasionally in last 1 year ? NO NA

ii) Alcohol (ML) - Beer/Wine/Hard Liquor. NO NA

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 iii) Are you taking drugs like Cannabis/Marijuana,Ecstacy,Heroin,LSD,Amphetamines or any other illegal drugs? NO NA

E. DECLARATION AND AUTHORISATION

1. DECLARATION BY PROPOSER/ JOINT LIFE

I/We hereby declare that I/We fully understand the meaning and scope of the Proposal form and the questions contained above and I am submitting the completed
proposal form of my/our own volition, and confirm that I/We have not been induced by anyone to make the Proposal. I/We have been explained the nature of
questions and the importance of disclosing all material information.

I/We further declare that all the statements and declarations herein shall be the basis of a contract between me/us and the Company and that I/We have made
complete, true and accurate disclosure of all the facts and circumstances and have not withheld any information that may be relevant to enable the Company to make
an informed decision about the acceptability of the Proposal. I agree that in case of any fraud or misstatement, action will be initiated as per Section 45 of Insurance
Act, 1938, as amended from time to time. I/We undertake to notify the Company, forthwith in writing, of any change in any of the statements made in the Proposal
subsequent to the signing of this proposal and before acceptance of risk and issuance of the Policy by the Company. The first and subsequent year premium will be
paid out of legally acquired source of income. I will provide information as and when required by the Company, acting on its own or under any order or instruction
received from Statutory Authorities, as regards to the sources of funds or utilizations or withdrawals. I agree that the Company may provide any information related to
me in respect of this proposal; as available to the Company at any time, to any Statutory Authority in relation to the any laws including the laws governing prevention
of money laundering, applicable in the country. To enable the Company to assess the risk under my/our proposal or for any other purpose in relation to the policy,
l/we, my/our heirs, administrators or executors or assignees hereby authorize my past or present employer(s)/business association/medical practitioners /other
agencies or governmental and/or any regulatory bodies, insurance repositories, CERSAI/ UIDAI, reinsurers / hospitals or diagnostic centres or TPAs/ other insurance
companies/ service providers/ National Health Authority (NHA) through ABHA to disclose and make available to the Company such details/records including financial
or medical records, as may be requested by the Company. I understand that I have disclosed my personal information with Max life and I hereby provide consent to
Max Life to share, store my information with its authorized service providers for servicing this policy/proposal such as issuance, underwriting renewal and claims
process with respect to this policy as per the regulation applicable from time to time. I/We submit the mandate to credit My / Our account towards all payments
against the above policy and agree and understand that payouts would be processed through electronic mode of payment and will be affected at select cities as per
facilities/ arrangements of Max Life Insurance. I/We authorize Max Life to send all communications by letter, E-mail, SMS. I/ We authorize Max Life to send all
communication by electronic means.

I do hereby certify that above stated information regarding the nationality and tax residential status is correct in all respects and may be used for all purposes,
including reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if any, to Max Life within 2 weeks of
occurrence of such change.

Signature / Thumb Impression / Electronic

Signature of Proposer/ Joint Life

Place: HYDERABAD Date: 24-07-2024

VERNACULAR /ILLITERATE DECLARATION

(Declaration to be made by a person unconnected with Max life Insurance Company Limited but whose identify can be easily
established.) I hereby declare that I have fully explained the contents of this proposal to the proposer/Life to be Insured in
language, as understood by him/her and that the left thumb impression/signature of the
proposer/Life to be Insured has been appended/affixed after fully understanding the contents thereof. I have truthfully recorded the
answers given by the Proposer/Life to be Insured.I have understood the content of the proposal form as explained to me in
language by the declarant, Mr./Ms. ,filling in the
proposal form and after the same, I am affixing my signature/thumb-impression.

Name of the Declarant: Address of the Declarant:

I hereby certify that I have understood the content of the proposal

form as explained to me in
language by the
declarant, Mr./Ms. , filling
in the proposal form and after the same, I am affixing my
signature/thumb-impression.

Signature / Thumb Impression / Electronic Signature of Signature / Thumb Impression / Electronic Signature of
Declarant Proposer / Joint Life

2. DECLARATION BY PRINCIPAL OFFICER/AGENT ADVISOR/SPECIFIED PERSON

I MR. MERUPULA NARESH do declare and confirm that I have met and explained the Product features, benefits, premium paying
term, nature of the questions contained in this Proposal form and other relevant terms and conditions to the Proposer and the Life Insured. I have also explained that
the answers to the questions forms the basis of the contract of the Insurance between the Company and the Proposer / Life Insured, 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 voidable at the option of the Company subject to section 45 of the Insurance Act, 1938 as amended from time
to time. I confirm that to the best of my knowledge the Life Insured does not suffer from any physical or mental abnormality or handicap or has / had been
hospitalised, undergone any surgery or treatment, or he /she is involved in activities including any 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 agent / corporate agent / specified person / broker prescribed by the Insurance Act 1938, as amended from time to time and
any other regulation, circular, instruction issued by IRDAI from time to time. I confirm that I have verified the identity, current / permanent residential address of the
Proposer/Life Insured, the nature of his/her business and his / her financial status basis the Max Life AML moral hazard checklist.

Is this a Replacement Sale? If yes, I have adequately explained the consequences of replacement sale to the customer. NO

Relationship of Principal Officer/Agent Advisor/Specified Person with the Proposer/ Joint Life/ Life Customer

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Insured
Name of Principal Officer/Agent Advisor/Specified Person Mr. Merupula Naresh
Principal Officer/Agent Advisor/Specified Person Code 49530B
Phone No. with STD Code:-7989663439
Date:- 24-07-2024 Place:- HYDERABAD

Signature / Thumb Impression / Electronic Signature of Principal

Officer/Agent Advisor/Specified Person :- 24-07-2024
Signature / Thumb Impression / Electronic Signature of Sales Manager 23-
07-2024 19:08:27
This system generated benefit Proposal form shall be treated as signed by
me.

Phone No. with STD Code:-7989663439

Date:- 24-07-2024 Place:- HYDERABAD

We confirm that we have made joint efforts in soliciting the prospect and will be jointly responsible for performing the service related to the policy. We further confirm
that the objective of sharing the commission is not for qualifying for any contest and/or reward & recognition programs of the company.

(Applicable only if more than one Agent Advisors share the commission)

Name(s) of Principal Officer/AA/Spec Person Principal Officer/AA/Spec Person Code Principal Officer/AA/Spec Person's Signature % Share

Mr. Merupula Naresh 49530B 23-07-2024 19:08:27 100

Important Notes: (1) Any payment/s including initial payment accompanying this proposal, cash or by bearer instrument must be made at any of the Company's
General Office only. (2) Crossed cheque or bank drafts must be made in favour of MAX LIFE INSURANCE COMPANY LIMITED ACCOUNT (Proposal No. as
above) maybe handed over to the Agent Advisor. (3) Receipt of the Completed Proposal and initial payment does not create any obligations upon the Company to
underwrite the risk. The Company shall not be liable until it has underwritten the risk and issued the Policy. 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. We draw your attention to Section - 39, 45 and 41 of the Insurance Act
, 1938 as amended from time to time, which reads as follows-

Section 39: In case nomination facility is availed, section 39 of the Insurance Act, 1938 as amended from time to time shall apply.

Section 45: No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of issuance of policy, from
the date of the Commencement of Risk or Revival of the policy or the date of the rider to the policy, whichever is later. However, Insurer may question the Policy at
any time within three years from the date of issuance of policy, from the date of Commencement of Risk or Revival of the policy or the date of the rider to the policy,
whichever is later, on the ground of fraud, in which case insurer shall inform Proposer/Life Insured/legal representatives in writing specifying the grounds and
materials on which such decision is based. For other details please refer to Section 45 of the Insurance Act, 1938 as amended from time to time.

Section 41: (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.For other details please refer to Section 45 of the Insurance Act, 1938 as amended from time to time.

Additional Declaration:

I am submitting my Electronic Application of my own volition and have understood the contents of the Electronic Application, and the relevant sales literature
including product features, benefits, applicable charges and am aware of the investment risk under the Policy.

I / We are aware that suitability information has been collected from me/us and recommendation on purchase of life insurance product has been made only basis
such information and any product selected by me/us that differs from such recommendation is on the basis of my/our personal choice. I / we have seen and
understood the benefit illustration shown to me / us on the screen electronically or provided to me / us in physical form, as the case may be. I / we have disclosed
all material information and not withheld any information that may be relevant to enable Max Life to take an informed decision about the acceptability of the
Electronic Application. I also confirm that the information in the Electronic Application, including the state of health and lifestyle habits of the life to be insured is
true and complete. I / we have submitted the confirmation number sent on my mobile number/ email id as a confirmation of the contents of the Electronic
Application and the benefit illustration and agreement to the terms therein.

I/We understand and agree that by submitting the Electronic Application, I / we will be bound by the statements / disclosures of material facts made therein in the
same manner, as if I / we have signed and submitted a written proposal for insurance to the Company and these shall be the basis of a contract between me/us
and the Company. I / we undertake to notify the Company of any change in statements made in the Electronic Application subsequent to its submission and
before acceptance of risk and issuance of the policy by the Company. I / we understand that in case the Company detects any fraud or mis-statement or
suppression of fact material to my/our life expectancy, the Company reserves the right to take appropriate action in accordance with Section 45 of the Insurance
Act.

I / we hereby declare and confirm that details provided in Form 60 attached to this Electronic Application (wherever applicable) are true and correct to the best of
my knowledge and belief. I declare that I do not have a Permanent Account Number and my/ our estimated total income (including income of spouse, minor child
etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which the above
transaction is held will be less than maximum amount not chargeable to tax.

I / we understand that the Company will not be liable unless the premium is received and realized by it within the time period stipulated for the same subject to
underwriting by it. I / we hereby authorize the Company to conduct screening / confirmation of my / our health status through medical examinations on the basis
of which, the Company may accept, decline or offer alternate terms on my proposal. I/we hereby authorize my past and present employer(s) / associate(s) /
medical practitioner(s) / any insurer or any other organization to disclose and make available to the Company my/our information.

I / We have filled the proposal electronically and have received the benefit illustration and filled up proposal form on email and registered mobile OR reviewed it
on tablet / desktop and after observing the said copy, I /we confirm that all the content / information therein is correct to the best of my / our knowledge.

Page 5 of 6
I have opted for the Combination Solution voluntarily (wherever applicable) as it would assist me in planning my finances. I also understand that these are
different products and can also be purchased separately.

I do hereby certify that above stated information regarding the nationality and tax residential status is correct in all respects and may be used for all purposes,
including reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if any, to Max Life within 2 weeks of
occurrence of such change.

Signature / Thumb Impression / Electronic Signature of Signature / Thumb Impression / Electronic Signature of Sales Manager 23-07-2024
Proposer/ Joint Life 24-07-2024 19:08:27

Phone No. with STD Code:7989663439

Abbreviations:

E/E = Employer-Employee
MWPA = Married Women Property Act
HUF = Hindu Undivided Family
CEIP = Corporate Employee Insurance Program
PIO = Person of Indian Origin
NRI = Non-Resident Indian
GST = Goods and Service Tax
TDS = Tax Deducted at Source

TRAD_STD_0324_5.12

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