KOTAK LIFETIME INCOME PLAN - PROPOSAL FORM
APPLICATION NO.: FORM ID NO: 30102035
FOR OFFICE USE ONLY
Proposal Number Cross Reference No. Branch Code Product Code
Proposal Receipt Date D D M M Y Y Y Y Client ID (for new Proposer)
Agent ID (Life Advisor/ Corporate Agent/Broker/ Relationship Officer)
CATEGORY TO WHICH THE PROPOSER BELONGS: Rural Urban Unorganised sector Economically Vulnerable / Backward Class Other Categories
OBJECTIVE OF INSURANCE: MWPA EMPLOYER-EMPLOYEE QROPS (UK pension fund transfer)
INSTRUCTIONS FOR FILLING UP THE FORM
1. Please answer all questions. 2. Please tick in the box where appropriate. 3. Please strike out parts which are not applicable and write 'N.A.'. 4. Strokes of the pen, dots and dashes will not be accepted as
replies. 5. This form is to be filled by the proposer himself/herself. 6. The proposer must sign any cancellation or alteration. 7. Insurance is a contract of utmost good faith thus you are required to disclose
all material and relevant facts. In case of any doubt as to whether a fact is material or not, the fact should be disclosed. As the statements in this proposal constitute warranties, complete and accurate
information must be given. 8. Please use additional sheet where space is not sufficient.
1. BASIC DETAILS
1.1 Are you an existing Kotak Life Pension Policyholder? Yes No 1.2 If yes, Client Id
1.3 Pension Policy number 1.4 Annuity Value (ü
any one): 1/3rd as cash lump sum and remaining as annuity 100% of the vesting amount
1.5 If this Annuity Policy is being taken through proceeds of any of Kotak Life’s Superannuation Plan, please enter Group Member Account Number
2. PARTICULARS OF THE PROPOSER (Please fill this section only if the Proposer & Annuitant are different)
2.1 Client Id (As policyholder or as nominee / Appointee / Trustee etc.)
2.2 Name of the Proposer Mr. Mrs. Ms Surname Given Name (include Middle Name, if any with space)
2.3 Maiden Name (for female proposers only) Surname Given Name (include Middle Name, if any with space)
2.4 Father's Name / Husband's Name Surname Given Name (include Middle Name, if any with space)
2.5 DOB D D M M Y Y Y Y 2.6 Gender Male Female 2.7 Nationality Indian NRI / PIO# Others
2.8 Permanent A/C No. (PAN) 2.9 PAN Copy enclosed Yes No 2.10 AADHAR No., if allotted
2.11 Annual Income in Rs. 2.12 Relationship with Annuitant
2.13 Occupation Salaried Professional Self Employed Retired Student House-wife Others Please specify
2.14 Age Proof Passport Driving License School / College Leaving Certificate PAN card Voter's Identity Card Others Please specify
2.15 Identity Proof Passport Driving License School / College Leaving Certificate PAN card Voter's Identity Card Others Please specify
2.16 Income Proof IT Returns Employer's certificate Audited P/L Accts Others Please specify
2.17 Current Address (Please leave a space between each part of address): L I N E 1
L I N E 2
CITY / DISTRICT STATE COUNTRY PINCODE
2.18 Telephone Number: Residence (ISD/STD) Mobile (CODE)
2.19 Address Proof Bank Statement Utility Bill* Passport Voter's ID Employer's Certificate Others Please specify
2.20 Email address
2.21 Do your bit for green world & Switch to e-communication. Kindly R
mark if you would like to receive your communication only through electronic mode
2.22 Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? Yes No : If you have an eIA, provide details:
a) Name of Insurance Repository b) eIA No:
c) Name as appearing in eIA:
2.23 If you do not have an eIA, would you like to open an account? Yes No If Yes, choose any one Insurance Repository: CAMSRep KARVY NDML CDSL
2.24 Additional Details - Indicator for Residence / Tax status: a) Place and Country of Birth: Place Country
b) Are you a citizen of any other country (dual / multiple) Yes No c) Are you a resident (for tax purposes) of any other country other than India Yes No d) Do you hold a green card
of US or any similar card for any other country? Yes No If answer to any / all of the above is yes, please do fill all the details in the Insurance FATCA Declaration.
2.25 Permanent Address (Please leave a space between each part of address) L I N E 1
L I N E 2
CITY / DISTRICT STATE COUNTRY PINCODE
2.26 Telephone Number: Residence (ISD/STD) Mobile (CODE)
#
Please fill in the NRI/PIO Questionnaire * not older than 6 months
APPLICATION NO.:
2.27 Address Proof Bank Statement Utility Bill* Passport Voter's ID Employer's Certificate Others Please specify
2.28 Preferred Communication Address : Current Address Permanent Address
2.29 Other Details:
A. Do you have any history of conviction under any criminal proceedings, in India or abroad? Yes No
B. Are you a politically exposed person (these are the people who hold prominent public function viz. Heads/Ministers of Central or State Govt., Senior Govt., Judicial or Yes No
Military Officials, Senior Executives of Govt. companies, important political party officials and immediate family members of above persons)?
If 'Yes' kindly give details (please attach additional sheet where space is not sufficient):
3. PARTICULARS OF THE ANNUITANT (Applicable only if different from proposer)
3.1 Client Id (As policyholder or as nominee / Appointee / Trustee etc.)
3.2 Name of the Annuitant Mr. Mrs. Ms Surname Given Name (include Middle Name, if any with space)
3.3 Maiden Name (for female proposers only) Surname Given Name (include Middle Name, if any with space)
3.4 Father's Name / Husband's Name Surname Given Name (include Middle Name, if any with space)
3.5 DOB D D M M Y Y Y Y 3.6 Gender Male Female 3.7 Nationality Indian NRI / PIO# Others
3.8 Marital Status Unmarried Married Widow(er) Divorcee
3.9 Permanent A/C No. (PAN) 3.10 PAN Copy enclosed Yes No 3.11 AADHAR No., if allotted
3.12 Annual Income in Rs. 3.13 Relationship with Proposer (only if annuitant is different from Proposer)
3.14 Occupation Salaried Professional Self Employed Retired Student House-wife Others Please specify
3.15 Age Proof Passport Driving License School / College Leaving Certificate PAN card Voter's Identity Card Others Please specify
3.16 Identity Proof Passport Driving License School / College Leaving Certificate PAN card Voter's Identity Card Others Please specify
3.17 Income Proof IT Returns Employer's certificate Audited P/L Accts Others Please specify
3.18 Current/Alternate Address (Please leave a space between each part of address): L I N E 1
L I N E 2
CITY / DISTRICT STATE COUNTRY PINCODE
3.19 Telephone Number: Residence (ISD/STD) Mobile (CODE)
3.20 Address Proof Bank Statement Utility Bill* Passport Voter's ID Employer's Certificate Others Please specify
3.21 Email address
3.22 Do your bit for green world & Switch to e-communication. Kindly R
mark if you would like to receive your communication only through electronic mode
3.23 Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? Yes No : If you have an eIA, provide details:
a) Name of Insurance Repository b) eIA No:
c) Name as appearing in eIA:
3.24 If you do not have an eIA, would you like to open an account? Yes No If Yes, choose any one Insurance Repository: CAMSRep KARVY NDML CDSL
3.25 Additional Details - Indicator for Residence / Tax status: a) Place and Country of Birth: Place Country
b) Are you a citizen of any other country (dual / multiple) Yes No c) Are you a resident (for tax purposes) of any other country other than India Yes No d) Do you hold a green card
of US or any similar card for any other country? Yes No If answer to any / all of the above is yes, please do fill all the details in the Insurance FATCA Declaration.
3.26 Permanent Address (Please leave a space between each part of address) L I N E 1
L I N E 2
CITY / DISTRICT STATE COUNTRY PINCODE
3.27 Telephone Number: Residence (ISD/STD) Mobile (CODE)
3.28 Address Proof Bank Statement Utility Bill* Passport Voter's ID Employer's Certificate Others Please specify
3.29 Preferred Communication Address : Current Address Permanent Address
3.30 Other Details:
A. Do you have any history of conviction under any criminal proceedings, in India or abroad? Yes No
B. Are you a politically exposed person (these are the people who hold prominent public function viz. Heads/Ministers of Central or State Govt., Senior Govt., Judicial or Yes No
Military Officials, Senior Executives of Govt. companies, important political party officials and immediate family members of above persons)?
If 'Yes' kindly give details (please attach additional sheet where space is not sufficient):
4. SPOUSE DETAILS (Applicable only for Lifetime Income with Last Survivor options)
4.1 Spouse Name
4.2 DOB D D M M Y Y Y Y 4.3 Gender Male Female 4.4 Contact No. (CODE)
4.5 Age Proof Passport Driving License School / College Leaving Certificate PAN card Voter's Identity Card Others Please specify
APPLICATION NO.:
5. PARTICULARS OF THE PLAN PROPOSED
5.1 Single Premium (Purchase Price) in Rs.
5.2 Mode of Payment: Cheque / DD Cash (Please pay at the nearest Kotak Life Insurance branch) Net-banking Credit Card
5.3 a) Cheque / DD No. b) Cheque / DD No. c) Amount in Rs.
d) Bank Name: e. Bank Branch:
5.4 Annuity Option (Select any one)
Lifetime Income Lifetime Income with Cash-back
Lifetime Income with term guarantee of 5 years Lifetime Income with term guarantee of 10 years
Lifetime Income with term guarantee of 15 years Lifetime Income with term guarantee of 20 years
Last survivor Lifetime Income with 100% annuity to Surviving Spouse Last survivor Lifetime Income with 100% annuity to the Surviving Spouse
Last survivor Lifetime Income with 50% annuity to Surviving Spouse and Cash-back on death of Surviving Spouse
5.5 Frequency of Annuity Payment: Monthly Quarterly Half-Yearly Yearly 5.6 Mode of Annuity Payment: Direct credit to Bank Account Cheque
5.7 Bank details for credit of Annuity Income / Refund (PLEASE ATTACH A BLANK CANCELLED CHEQUE LEAF)
Bank Name: Branch Name:
Bank A/c No: IFSC MICR code
Name of A/c Holder (as reflecting in Bank A/c)
5.8 Bank Address:
CITY / DISTRICT STATE COUNTRY PINCODE
6. NOMINEE DETAILS (To be filled for Lifetime Income with cash-back / Lifetime Income with term guarantee / Last survivor Lifetime Income with
100% annuity to the Surviving Spouse and Cash-back on death of Surviving Spouse option only)
6.1 Nominee Name
6.2 % share* 6.3 Date of Birth: D D M M Y Y Y Y 6.4 Gender Male Female
6.5 Address:
CITY / DISTRICT STATE COUNTRY PINCODE
6.6 Contact No. (CODE) 6.7 Relationship with Annuitant
* In case of more than one nominee, please fill in the Additional Nominee Form. Please ensure that the total of the shares amount to 100%.
7. PARTICULARS OF APPOINTEE (WHERE THE NOMINEE IS A MINOR)
7.1 Appointee Name
7.2 Date of Birth: D D M M Y Y Y Y 7.3 Relationship with Nominee 7.5 Contact No. (CODE)
7.4 Address:
CITY / DISTRICT STATE COUNTRY PINCODE
8. DECLARATION BY THE PROPOSER / ANNUITANT
I understand that the annuity rates applicable at the date of Acceptance of proposal shall be applicable and guaranteed for the term of the policy. I declare that I have answered the questions in
the Proposal Form after having fully understood the nature of the questions and the importance of disclosing all information while answering such questions. I also hereby declare that the
answers given by me to all the questions in the proposal form are true and complete in every respect and that I have not withheld any material information or suppressed any fact.
I also hereby authorize my employer, to divulge to the Company any information required by it in connection with this proposal form and the policy contract that may be issued pursuant to
this proposal. I further declare that the statements/submissions made by me in this Proposal Form [including any addendum(s) thereto / all declarations, affidavits and other statements]
and/or any information sought for by the Company from any person authorised by me to provide such information, relied upon by the Company to assess the risk on my life under this
Proposal Form shall form a basis of the contract of Annuity between me and the Company. And if any untrue statement is contained in the Proposal Form [including any addendum(s)
thereto] /any of the above documents or statements, or if there has been a non-disclosure of a material fact the Company shall have the right to vary the benefits/ treat the Policy as void and
all premiums paid under the policy may be forfeited to the Company subject to the provisions of Section 45 of Insurance Act, 1938 as amended from time to time.
I understand that the contract will be governed by the provisions of the Insurance Act, 1938 as amended from time to time, the IRDA Act, 1999 and the Regulations framed there under and
that the contract will not commence until the Company's written acceptance of this Proposal Form is received. I hereby confirm that all premiums will be paid from bonafide sources and no
premiums will be paid out of proceeds of crime related to any of the offence listed in Prevention of Money Laundering Act, 2002.
Please paste latest
Please paste latest
Please paste latest self-signed photograph
self-signed photograph
self-signed photograph of the spouse
of the Proposer
of the Annuitant (for any of the Last Survivor
(if different from Annuitant)
Lifetime Income Options)
Place Place Place
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Signature / Thumb impression of the
Signature / Thumb impression of Signature / Thumb impression of the spouse (for any of the Last Survivor
Proposer (if different from Annuitant) Annuitant Lifetime Income Options)
APPLICATION NO.:
Proposer’s Witness:
Name: Signature
Signature
/ ThumbofImpression
Proposer’s of
Witness
the Proposer
Date: D D M M Y Y Y Y
Kotak Mahindra Life Insurance Company Ltd. Witness:
Name: Signature of KLI Witness
Date: D D M M Y Y Y Y
9. DECLARATION FOR ONLINE TRANSACTIONS RIGHTS
I have read the terms and conditions of registration on Kotak Life Insurance website - [Link] and
accept them. I understand that I will have to register on [Link] to receive my username and
password. I agree that all transactions executed over the website [Link] under my username and
password will be binding on me. I understand that I get transaction rights for proposal number mentioned above provided Signature / Thumb impression of Proposer
my application is accepted by Kotak Life Insurance.
Date: D D M M Y Y Y Y Place:
10. DECLARATION BY THE PERSON FILLING IN THE FORM (Applicable only where form is filled in by a scribe or signed in vernacular languages)
I ___________________________________________________________ (Full Name), have explained to the Proposer, that the answers to the questions form the basis of the contract of Annuity
between the Company and the Proposer and that if any untrue statement is contained therein the Company shall have the right to vary the benefits which may be payable and further if there has been a non-
disclosure of a material fact the policy may be treated as void and the Policy will be cancelled immediately by the Company in accordance with the Section 45 of the Insurance Act, 1938 and amendments
thereto from time to time and all premiums paid under the policy may be forfeited to the Company. I also confirm that the Proposer has signed / affixed his/her right thumb impression in my presence.
Address:
VILLAGE / DISTRICT L A N D M A R K
CITY / DISTRICT STATE COUNTRY PINCODE
Telephone Number: Residence (ISD/STD) Mobile (CODE)
I, the Proposer declare that the contents in the proposal form have been fully explained to me and I have fully understood the significance of the proposed contract.
Signature of the Life Advisor / Specified person
Signature of scribe Signature / Thumb impression of the Proposer of Corporate Agent /Authorised Employee of Broker /
Relationship Officer
SECTION 41 OF THE INSURANCE ACT, 1938: (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 liable for a penalty which may extend to ten lakhs rupees.
SECTION 45 OF THE INSURANCE ACT, 1938: The provisions of Section 45 of the Insurance Act, 1938 are applicable in the above contract. Please refer to Section 45 either on our website or
contact our intermediary or visit the nearest branch for the full text.
FREE LOOK PERIOD: The policyholder is offered 15 days free look period for a policy sold through any of the channels (except for Distance Marketing Channel which will have 30 Days) from the
date of receipt of the policy wherein the policyholder may choose to return the policy within 15 days / 30 days of receipt if s/he is not agreeable with any of the terms and conditions of the plan and receive
the applicable refund amount.
Free-look option will not be available in case of existing customers, where it is compulsory to purchase annuity from Kotak Life Insurance.
Note: Proposer is advised to read and understand the product features, benefits & risk factors, structure of charges, terms and conditions of the proposed plan as set forth in the related brochure(s)
available on the Company’s website [Link].
11. DECLARATION BY THE LIFE ADVISOR/CORPORATE AGENT/BROKER/RELATIONSHIP OFFICER (please cancel what is not applicable and fill all details)
I, ________________________________________________________ (Full name of the Life Advisor/Specified person of the Corporate Agent/ Authorised Employee of the broker/ Relationship
Officer) in my capacity as the Life Advisor/Specified Person of the Corporate Agent/Authorised Employee of the Broker/ Relationship Officer, do hereby declare and confirm that I have explained the all
the contents of this proposal form, including the nature of the questions contained in this proposal form to the proposer. I have also explained that the statement(s), information and response(s) submitted
by him/her in this proposal form to the questions contained herein or any details sought herein will form the basis of the contract of annuity between the Company and the proposer, if this proposal is
accepted by the Company for issuance of a policy. I have also explained that the rates may change every two weeks and in such a case, the rate guaranteed will be as on the money realisation date or the
date of conversion, whichever is later.
I have further explained that if any untrue statement(s)/information/ response(s) is/are contained herein / including any addendum(s), affidavits, statements, submissions furnished / to be furnished, the
Company shall have the right to vary the benefits which may be payable and furthermore if there has been a non-disclosure of any material fact, the policy issued in his/her favour pursuant to this proposal
may be treated by the Company as null and void and all premiums paid under the policy may be forfeited to the Company. Based on my interaction with the proposer and/or the documents and records that
I have been supplied with, I have no information, which suggests that any of the statement(s), information and response(s) supplied by the proposer or the life to be insured is/are incomplete or untrue.
Licence No. (Life Advisor/Corporate Agent/Broker/Relationship Officer)
Agent ID (Life Advisor/Corporate Agent/Broker/Relationship Officer)
Place: Date: D D M M Y Y Y Y
(Signature of the Life Advisor/Specified person of Corporate
Agent /Authorised Employee of Broker/ Relationship Officer)
Tel. No:
APPLICATION NO.:
12. AGENT’S CONFIDENTIAL REPORT
i) Name of the Annuitant(s) / Proposer:
ii) Name of the Proposer (Incase different from Annuitant):
# Annuitant(s) Proposer
1. How long have you known the Annuitant(s) / Proposer?
2. How have you been introduced to the Annuitant(s) / Proposer?
- Long term relationship. No of years:
- Cold call
- Referral if yes, Referred by name & contact details
3. When have you last met the Annuitant(s)/Proposer? (DD/MM/YY)
4. Have you personally met the Annuitant(s) / Proposer? Yes No Yes No
5. Are you related to the Annuitant(s) and Proposer?
Yes No Yes No
(If Yes, pls. mention the relationship & provide an MHR from Sales Manager)
6. Are you satisfied with the Financial condition and income earning capacity of the Annuitant(s) / Proposer? Yes No Yes No
7. Have you explained the Product features, benefits & the premium paying term for the plan applied by the client? Yes No Yes No
8. Is there any other information you would like to provide? Yes No Yes No
9. Do you recommend the proposal for annuity? Yes No Yes No
Date: D D M M Y Y Y Y Place:
(Signature of the Life Advisor / Specified person of Corporate
Agent / Authorised Employee of Broker / Relationship Officer)
Name of Advisor
FOR OFFICE USE ONLY CHECKED BY
NAME OF SALES MANAGER NAME OF SALES ASSOCIATE PROMOTION CODE NAME OF BOE
SALES MANAGER ID SALES ASSOCIATE ID PARTNER CODE BRANCH NAME
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
SIGNATURE OF SALES MANAGER SIGNATURE OF SALES ASSOCIATE SIGNATURE SIGNATURE OF BOE
Kotak Mahindra Life Insurance Company Ltd.
(Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.)
IRDAI Regn. No.: 107, CIN: U66030MH2000PLC128503, Regd. Office: 2nd Floor, Plot # C-12, G-Block, BKC, Bandra (E), Mumbai - 400 051.
[Link]
the proposal for Life Insurance with Kotak Mahindra Life Insurance
OR "KOTAK MAHINDRA LIFE INSURANCE COMPANY LTD."
FOR YOUR REFERENCE
1. This is an acknowledgement by the Life Advisor/Specified person of Corporate Agent/Authorised Employee of Broker / Relationship Officer of having received the
Proposal Form. This is not a receipt issued by Kotak Mahindra Life Insurance Company Ltd.
2. Kotak Mahindra Life Insurance Company Ltd. shall issue a proposal deposit receipt (PDR) on receiving the completed proposal form with the cash / cheque /
demand draft at its branch office.
3. In case of non-receipt of your PDR or for any clarification, kindly contact nearest Branch of Kotak Life Insurance.
4. For further assistance, do write to us at clientservicedesk@[Link]
clientservicedesk@[Link]
[Link]
Kotak Mahindra Life Insurance Company Ltd.
(Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.)
CIN: U66030MH2000PLC128503, Regn. No. 107, Regd. Office: 2nd Floor, Plot # C-12, G-Block, BKC, Bandra (E), Mumbai - 400 051.
[Link]