Enrolment Form No: 8800425746

UIN: 136N024V07 Member Enrolment Form for

Canara HSBC Life Insurance Group Secure
(Please use in boxes to indicate choice. Please fill the direct debit/ NACH/ SI mandate) FOR CANARA BANK
162001996475
File/Loan A/c No:___________________________________ 325561195
Customer ID: ____________________________________ 01/02/2025
Loan Disbursement date: _____________________________
0683
Branch Code/RAH Code: ___________________________ Indian institute of science
Branch Name : __________________________________ Staff : Yes ✔ No
000000
Bank MO Code: _____________________________________ :_________________________ Canar HSBC Life Insurance employee
Canar HSBC Life Insurance employee code 99029096
Name :_______________________________
Kay Vijaya Kumar
DETAILS OF MEMBER TO BE INSURED
SONU KUMAR SINGH
Full Name______________________________________________________________________________________________________________________________________________________
First Middle Last
01/01/2004 Are you a: Resident of India ✔ NRI / PIO Foreign National
Date of birth: ______/__________/__________ Gender: Male ✔ Female Transgender
(Please fill NRI/PIO/Foreign national questionnaire as relevant)
No 203 ambedkar nagar , Tanki side dhurwa , Ranchi Jharkhand , JHARKHAND
Communication Address _______________________________________________________________________________________________________________________________________
Ranchi 834004 INDIA
____________________________________ City:_________________________ Pin Code:_______________________________________Country_____________________________________
7464072070 sonusingh@[Link]
Contact No.: _________________________________ E- mail: __________________________________________________________________________________________________________
Indian
Current Country of residence ____________________________________________________________________________________________________________________________________

Do you need physical copy of your Certificate of Insurance (COI) ? Yes No ✔

Occupation: Salaried Self Employed Others ✔ Student

if other, please specify _______________________________________________

Employer’s name & address: ______________________________________________________________________________________________________________________________________

Occupation Designation / Description : ______________________________________________________________________________________________________________________________

Student

Occupation: Armed Forces Merchant Marine Oil and Natural Gas Aviation Industry Chemical Industry Others
NA
e-Insurance Account Number (eIA) ________________________________________________________________________________________________________________________________

Name of the Insurance Repository to which eIA is linked CAMS CSDL KARVY NSDL

If you do not have an eIA account, would you like to create one? Yes ✔ No

If Yes, please name the preferred Insurance Repository CAMS CSDL KARVY NSDL

Are there any risks associated with your occupation? E.g : Working with boiler, explosives, chemicals etc. Yes No ✔
Do you take part in hobbies that are risky in any way? E.g aviation, diving, mountaineering, etc. Yes No ✔

Nominee Details:
Mr SHAMBHU KUMAR SINGH
Name Mr\Ms_______________________________ Father
who is related to insured member as__________________ 01/01/1981
D.O.B.________________________ Male
Gender _________________________

NA
In case nominee is a minor, please provide appointee details: Mr\Ms ______________________________________________ NA
who is related to me as__________________________________

NA
D.O.B. __________________________________________________ NA
Gender:_______________________________________

Do you want nominee/appointee`s communication address same as mentioned above Yes No. If No, then please provide the address in the relevant section overleaf.

INSURANCE/LOAN DETAILS
Moratorium Period (Not applicable for Personal Loan, LAP, 2
Type of loan: Education Loan Loan Term (including moratorium if any): 20 Years Wheeler and 4 Wheeler Loans)
Coverage Term 15 60

Premium Payment Term: ✔ Single Play coverage option: level ✔ Reducing Premium frequency (Not applicable for single pay option) Annual Monthly

Benefit Option: Death cover ✔ Death + TPD cover* (Death + TPD cover only available for Sum Assured up to ` 1 crore.)
1069800.0
Sanctioned/ Outstanding loan amount (in `) ____________________________________ 1069800
Sum Assured at inception (in ` ): _____________________________________________
__________________________________________________________________________ _____________________________________________(should be <=120% of loan amount)

Joint Life : Yes No ✔ Joint Life Option: a) Joint basis b) Loan share basis
If Yes : Primary borrower Co-borrower
If Yes, please tell no. of joint borrowers ____________________ Loan share (for loan share basis) %

Premium Payable (Year 1) inclusive of Goods and Services Tax & applicable cess(es)/levy, if any (in `):___________________________________________________________________
24035.0
Premium Payable (Year 2 onwards) inclusive of Good and Services Tax & applicable cess(es)/ levy, if any (`): ___________________________________
NA (Not applicable for Single Pay)

HEALTH DETAILS OF MEMBER TO BE INSURED

Height:________________cm
173 Weight:_____________
60 Kg
1. During the last five years, have you consulted a doctor or have been advised to undergo any medical investigation or treatment for any medical condition
Yes ✔ No
(other than minor cough, cold or flu), or had a surgery, or been hospitalized
2. Are you currently taking, or have you previously taken, any medication or treatment for a continuous period of more than 14 days for any condition, other than for minor
Yes ✔ No
coughs, cold, flu, typhoid?
3. Has your proposal for life, health or accident insurance or application for reinstatement for any of these ever been declined, postponed, withdrawn or accepted at extra
Yes ✔ No
premium or reduced cover?
4. Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the following conditions? If answer to this question is YES then please tick the
Yes ✔ No
relevant box given below
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 Yes EŽ

MEMBERSHIP FORM ACKNOWLEDGEMENT (to be mandatorily filled in by staff)

This is to confirm receipt of Membership form from Mr/Ms ___________________________________________________for the insurance cover under Canara HSBC Life Insurance Group Secure
Plan issued by Canara HSBC Life Insurance Company Limited, Reg. No 136 (“Company”). Acceptance of risk cover is subject to underwriting acceptance and merely submitting the Member
Enrollment Form shall not construe as acceptance of the cover and issuance of the Policy. The Insurance Cover shall commence from the date mentioned in the Certificate of Insurance.

Name : ______________________________________ Date : _____________________________________

File/Loan Account No.: ____________________________________________________________________ Signature and Rubber

Stamp of Branch Official
PAYMENT DETAILS (For Official Use Only)

Payment mode: Cheque   Credit Card  Online transfer  24035.0

Others (please specify)______________________ Amount:________________________
_______________________
NA Date______________________________________________
20/25/0201 Bank Name:________________________________________
Canara bank

SONU
Name as per Bank records: _______________________________ Bank Name: ______________________________________
Canara bank Branch:__________________________________________
110185207323
A/C No. ________________________________________ Saving Account
A/C Type_______________________________________ CNRB0002730
IFSC Code:_______________________________________________
Nominee Address (if different from Life assured`s address)
Communication Address:__________________________________________________________________________________________________________
No 203 , JP Market dhurwa , Ranchi Jharkhand , JHARKHAND City: _________________________
Ranchi
834004
Pin code: _____________________ 6201344894
Contact No.: ________________________________________________
Appointee Address (if different from Life assured`s address)
Communication Address: _______________________________________________________________________________________________________________________________________
NA
NA
City: _____________________________________________ NA
Pin code: _____________________________________________ NA
Contact No.: __________________________________________

Authorization for Claim payment (applicable only if Master Policyholder is one of the following entities: (i) RBI regulated Scheduled Commercial Banks (including Co-operative Banks); (ii) NBFCs
having Certificate of Registration from RBI; (iii) National Housing Bank (NHB) regulated Housing Finance Companies), (iv) National Minority Development Finance Corporation (NMDFC) and its State
channelizing agencies (v) Small Finance Banks regulated by RBI(iv) National Minority Development Finance Corporation (NMDFC) and its State channelizing agencies (v) Small Finance Banks
regulated by RBI, (vi) Mutually Aided Cooperative Societies formed and registered under the applicable State Act concerning such Societies, (vii) Microfinance companies registered under section
8 of the Companies Act, 2013, (viii) Any other category as approved by the Authority
On the happening of any event/contingency covered under this policy, I hereby expressly authorize the Company to settle any insurance claim proceeds that is due to me under the policy directly
in favour of the Master Policyholder to the extent of the amounts outstanding under my loan number _____________________________________availed from the Master Policyholder. The
balance insurance claim proceeds if any, after settlement of the outstanding loan amount shall be paid to me or my nominee or legal heirs as the case may be. In order to discharge the outstanding
loan amount if any directly to the Master Policyholder, the Company can solely rely upon the Credit Account statement in respect of my loan account provided by the Master Policyholder, for
ascertaining amounts outstanding from me under the said loan. I hereby declare that the payment of the outstanding loan amount if any directly by the Company to the Master Policyholder shall
constitute a valid and sufficient discharge to the Company.

Declaration & Authorization for Enrolment by Life to be Insured:

I declare and warrant that information provided in this Member Enrolment Form is correct, complete and true. I understand that the information provided in this Health Questionnaire together
with the application for insurance on my life and any other documents relative thereto, shall be the basis of the proposed Coverage. I am aware that the withholding of, or omission or failure to
disclose, any medical or financial information will invalidate my Insurance Cover. I agree to inform the Company in writing of any change in my health and circumstances between the date of this
Declaration and the issue of the Certificate of Insurance in respect of my Life Insurance Coverage. I irrevocably authorise and request any entity like a doctor/hospital/employer (past and
present) who may be in possession of, or hereafter acquire, any information concerning my health including blood tests/HIV antibodies, to disclose such information to Canara HSBC Life
Insurance and I agree that this authority and request remain in force. I hereby give my consent to undergo HIV1/2 test by ELISA method. I am aware that this test is only for screening purposes
and not confirmatory for HIV/AIDS. The Company may also share the same or any other personal information related to me with hospitals/diagnostic centers, reinsurers, Life Insurance council/
association, investigation/verification agencies or vendors as it deems necessary for issuing and administering the policy of insurance. In case I have an objection to usage of my personal
information for the purposes mentioned above, I shall intimate the Company prior to its acceptance of my proposal and issuance of the policy, in which case the Company shall cancel the proposal,
refund the proposal deposit and delete all sensitive personal information relating to me from its records/systems.

Canara HSBC Life Insurance Company Limited

(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Corporate Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: Unit No. 208, 2nd Floor, Kanchenjunga Building, 18 Barakhamba Road, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825
Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 7039004411
E-mail us at customerservice@[Link] Visit our website at [Link]
 I/We hereby authorize Company to send me any information relating to my proposals / policies through SMS on the phone number/email address provided by me or through any other mode.
I/ We declare that the premiums paid/ payable shall not be generated from the proceeds of any criminal activities/ offenses and I/We shall abide by and conform to the Prevention of Money
Laundering Act, 2002 or any other applicable laws.
I also declare that I/ we do not have any address in Japan/ Indonesia; I/we am/are not Politically Exposed Persons#; My/our nature of work/business/activities does not involve any association
with Money services businesses*/State run lotteries/casinos/gaming activity/gambling/horse jockey/jockey club/Not for profit organization/Trusts/charities or Organizations involved in
promoting social, religious, humanitarian cause, real estate /jewelers/precious stones dealers or scrap dealers.
In case any of this applies, please provide details ___________________________________________________________________________________________________________
#
(PEPs are individuals who are or have been associated with a political party/politician or holding any senior role in any ministry/government/state owned enterprises/judicial body/ military/police
in India or abroad or those individuals who have any close family members or associates in the said capacity).
*Money service businesses are entities/proprietorship concerns offering services involving currency exchange/dealer/exchange house/third party payment processors/payment/collection agents
etc which are not registered as banks.
Anti-Tying Declaration:
I am aware that the purchase of insurance is totally optional, has no bearing on the loan decision and is at my sole discretion.
I hereby apply to be a Life Insured under the master policy issued to Canara Bank
And I agree to
Pay the premium myself via Direct Debit (Please fill the direct debit mandate). I hereby authorize Canara Bank to debit my account by direct debit as per request from Canara HSBC Life
Insurance Company Ltd. for collection of the insurance premium for enrolment as member or premium for renewal in the subscribed plan.
Add the above premium to the loan amount

Signature/Thumb impression: Electronically

_______________validated through
_________ OTP_____
______ ____ on 01/02/2025
__________________ _____ Name I hereby declare that I have explained the product and terms and conditions
of this product in the language understood by the proposed insured member
of Member to be insured: _________ _______________ _______________ _______________ __________ Date: and that he/she has understood the significance of the proposed insurance
cover. This membership form has been signed in my presence. In case of
direct debit, I have taken the consent of the proposed insured member in
_________________ _________________ _________________ ___________________ _________ Place: direct debit mandate/authorization form.
_________________ _________________ _________________ ___________________ _________ Signature and Stamp of Bank Official: _______________________________

Name & employee code of Bank official:_____________________________

As per Section 41 of the Insurance Act, 1938 (as amended from time to time)
(1) 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.

Section 45 of Insurance Act, 1938 (as amended from time to time)

(1) 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, i.e., from the date of issuance of the policy or the date
of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy
or the date of the rider to the policy, whichever is later, on the ground of fraud: Provided that 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.
Explanation I- For the purposes of this sub-section, the expression “fraud” means any of the following acts committed by the insured or by his agent, with the intent to deceive the insurer or to
induce the insurer to issue a life insurance policy:
a. the suggestion, as a fact of that which is not true and which the insured does not believe to be true;
b. the active concealment of a fact by the insured having knowledge or belief of the fact;
c. any other act fitted to deceive; and
d. any such act or omission as the law specifically declares to be fraudulent.
Explanation II- Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the circumstances of the case are such that regard being had to them, it is the
duty of the insured or his agent, keeping silence to speak, or unless his silence is , in itself, equivalent to speak.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement of a 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 of or suppression of a material fact are
within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation –A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation of the contract, to be the agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy
or the date of the rider to the policy, whichever is later, 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 basis of which the policy was issued or revived or rider issued:
Provided that 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
to repudiate the policy of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on ground of fraud, the premiums collected on the policy till the
date of repudiation shall be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the date of such repudiation.
Explanation- For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered material unless it has a direct bearing on the risk undertaken by the insurer,
the onus is on the insurer to show that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this sections 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 Assured was incorrectly stated in the proposal.

Canara HSBC Life Insurance Company Limited

(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Corporate Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: Unit No. 208, 2nd Floor, Kanchenjunga Building, 18 Barakhamba Road, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825
Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 7039004411
E-mail us at customerservice@[Link] Visit our website at [Link]
 CUSTOMER INFORMATION SHEET / KNOW YOUR POLICY
This document provides key information about your
Group Insurance Membership.
You are also advised to go through your Certificate of
Insurance(COI)

Sl Title Description COI Clause

No. (Please refer to applicable COI Number
Clause Number in next column)
1 Name of the Canara HSBC Life Insurance Group Secure -
Insurance Group Non-Linked Non-Participating Pure
Product and Risk Premium Credit Life Insurance Plan
Unique UIN 136N024V07
Identification
Number (UIN)
2 Master Policy Master Policy Number / -
Number/ Member Enrollment Number - 8800425746
Member
Enrollment
Number
3 Type of Group Non-Linked Non-Participating Pure -
Insurance Risk Premium Credit Life Insurance Plan
Policy
4 Basic Policy Single/ Instalment Premium: ₹ 20369.0 -
details

Premium Payment Mode: single -

Sum Assured on death: ₹ 1069800 (Initial -
Sum Assured)
Sum Assured on Maturity: Not applicable -
Premium payment Term: Single Premium -
Policy Term: 180 Months -

5 Policy Benefits payable on maturity: Not applicable -

Coverage/
benefits
payable
Benefits payable on death: Clause 1
Following is applicable for an in-force policy:
level cover Sum Assured. On the payment of
this benefit, Insurance Cover shall cease for
that Insured Member
reducing cover Sum Assured as per Sum
Assured Schedule. On the payment of this
benefit, Insurance Cover shall cease for that
Insured Member
Survival benefits excluding that payable on -
maturity: Not applicable
Surrender benefits: Clause 6
level cover: Not applicable
reducing cover ,regular premium Not
applicable
reducing cover ,single premium Available
from the end of first year
reducing cover ,limited premium Available
only after three years have elapsed
Options to members for availing benefits, if Clause 6
any, covered under the policy: Cover
continuance Option
Other benefits/ options payable, specific to Clause 2
the policy, if any: Total & Permanent
Disability Benefit (TPD), If Opted
 Lock-in period: Not applicable -
6 Options Not applicable -
available (in
case of Linked
Insurance
Products)
7 Option Not applicable -
available (in
case of Annuity
product)
8 Riders opted, if Not applicable -
any

9 Exclusions • Suicide Exclusion Clause 7

(events where • 45 Days Exclusion for claim except a
insurance death/TPD claim arising on account of an
coverage is not Accident
payable), if • Total & Permanent Disability Benefit
any Exclusion
10 Waiting/ lien Not applicable -
Period, if any

11 Grace period non single pay policies non single pay

• 30 days in case of yearly, half-yearly and policies
quarterly premium payment mode Clause 5 single
• 15 days in case of monthly premium pay policies -
payment mode
single pay policies Not applicable
12 Free Look 30 days from the date of receipt of Clause 20
Period Certificate of Insurance, whether received
electronically or otherwise (whichever is
earlier).
13 Lapse, paid-up Lapse: single pay policies Not applicable Clause 12
and revival of non_single pay policies On non-payment of
the Policy due premium within the Grace Period
Reduced Paid-up: Not applicable -
Revival: non single pay policies A lapsed non single pay
Insurance Coverage can be revived within 5 policies
years of the due date of the first unpaid Important
premium single pay policies Not applicable definitions of COI
single pay
policies NA
14 Policy Loan, if Not applicable -
applicable

15 Claims/ Claims Turn Around Time (TAT) for death claims -

Procedure settlement:
• Last document to settlement (Non-
investigation cases) – 30 days
• Intimation to settlement (Investigated
cases) – 120 days
Above shall be aligned to comply with the
Regulatory changes, if any at all times.
Claims procedure:
Step 1 – Claim Intimation & Registration:
The nominee/ claimant can intimate about
the claim by filling the Claim Form and
sending it to Insurer at head office/ nearest
Bank branch/ Insurer offices or online along
with mandatory documents.
Step 2 – Claim Processing: Special Claim
Team will assess the claim and inform in
case any further document is needed to be
submitted.
Step 3 – Claim Settlement: Once the claim is
 intimated, and all the relevant documents
are received, the claim decision shall be
taken.
Helpline/ Call-centre number: 1800-103–
0003 / 1800-891-0003
Contact details of the Insurer: https://
[Link]/contact-us/
contact-details
Register and track claim at:
Customer Portal: https://
[Link]/#/login
Customer service App:
For android mobile: [Link]
store/apps/details?
id=[Link]&hl=en_IN
For ios: [Link]
canara-hsbc-life/id1637840399
Link for downloading Claim form & list of
documents required: https://
[Link]/claims
16 Policy Turn Around Time (TAT): -
Servicing • Free-look cancellation - Within 7 days from
date of request or last necessary document
received
• Surrender– Within 15 days from date of
request or last necessary document
received
• Survival payouts – Not Applicable
Helpline/ Call-centre number: 1800-103–
0003 / 1800-891-0003
Contact details of the Insurer: https://
[Link]/contact-us/
contact-details
Download forms, access list of documents
and/or place service request through
following modes:
• Customer Portal: https://
[Link]/#/login
• Customer service App:https://
[Link]/app-
[Link]
• Email:
:customerservice@[Link]
• Walk-in to any of our nearest branches
17 Grievances/ Complaint Redressal: Toll Free: -
Complaints 1800-103-0003 / 1800-891-0003
email:cru@[Link]
Website link for registering
complaints:[Link]
contact-us/grievance-redressal
Resolution time: two weeks
Escalation: Grievance Redressal Officer:
Canara HSBC Life Insurance Company,
139P, sector 44, Gurugram - 122003,
Haryana, India. Toll Free: 1800-103-0003 /
1800-891-0003 email:
gro@[Link] Incase not satisfied
or no response received from Us within 2
weeks, you can register complaint at Bima
Bharosa [Link]
Toll Free No: 18004254732/155255, Email
ID: complaints@[Link]. Or You can
approach Insurance Ombudsman of your
respective State, if you do not receive
response from us within 30 days from the
date of filing the complaint or if your
 complaint is rejected or if you are not
satisfied with our response. Kindly refer the
website at [Link]
Ombudsman for the list of Ombudsman and
office details.
Declaration by the member
I have read the above and confirm having noted the details.
Date : 01/02/2025
Place :
Electronically validated through OTP on 01/02/2025
(Signature of the member)
Note: Incase of any conflict, the terms and conditions mentioned in the policy document shall
prevail.
 Other Questionnaire

Application No: 8800425746 Name of the Insured: SONU KUMAR SINGH

 Medical Questionnaire

Application No: 8800425746 Name of the Insured: SONU KUMAR SINGH