Member Enrolment Form-GTL-without Addendum-19 Nov 2018

MEMBER ENROLMENT FORM FOR
FUTURE GENERALI GROUP TERM LIFE INSURANCE PLAN (UIN 133N003V03)

To be filled in by Master Policyholder*
Certificate No.* ID No.*
To be filled in by Member to be insured

Full Name First Name
Middle Name
Surname
Date of Birth D D M M Y Y Y Y Gender Male Female Current Occupation
Designation Nature of Duties
Corres- House No. Society/Apartment
pondence Road Name Landmark
Address City State
Country Pincode
Permanent House No. Society/Apartment
Address Road Name Landmark
City State
Country Pincode
Contact No. Nationality Country
Email ID
Nomination Details
Name of the Nominee (First Name Relationship of Nominee with Date of Birth Contact Number Correspondence Address (House No., Society / Apartment, % Share
/ Middle Name / Surname) the member to be insured (DD/MM/YYY) Road Name, Landmark, City, State, Country, Pincode
Nominee 1
Nominee 2
Nominee 3
If nominee is minor Ms./Mr. whose age is atleast 18 years last birthday
as appointee to receive the benefits payable in the event of my death during the minority of the nominee and shall hold the said money in trust for the benefit of nominee till nominee
attains the age of majority.
Relationship of Appointee with the Nominee Date of Birth of the Appointee D D M M Y Y Y Y
Contact Number of Appointee
Corres- House No. Society/Apartment
pondence Road Name Landmark
Address City State
Country Pincode
Sum Assured
**Please note that the maximum amount of cover under Group Master Policy Number for any one insured member is .
No cover above will be available even if more enrolment forms are filled in
Health details of Proposed Insured (Please use ü in boxes to indicate choice)

Height cms Weight kg Sum Assured
1. Are you currently in good health? Yes No
2. Please answer ‘Yes’ or ‘No’ if any of the following is true
a. Are you suffering from Heart Disease, stroke, cancer, hepatitis, disease of urinatory system or mental illness ,Diseases of the respiratory system Yes No
(e.g.) Tuberculosis, asthma, persistent cough, pneumonia, disease related to Digestive system /Liver disorder / reproductive organs?
b. Have you ever had or been advised to undergo hospital treatment or surgery? Are you currently on any medication/treatment? Yes No
c. Have you ever had or been advised to have a blood test for AIDS or an AIDS related condition or have you ever been refused or blood donor? Yes No
d. Have you consulted a physician for any reason other than minor impairments such age cold or flu. Including routine examinations and blood tests, Yes No
or have received any blood transfusion in past?
e. Do you take part in or have you any prospect or intention of taking part in any hazardous sport, hobbies or pursuits like aviation, diving Yes No
mountaineering etc?
If answers to any of the questions (Q2 a,b,c,d or e) is ‘Yes’ please give full details in the particulars below, such as medical history, diagnosis, date of diagnosis, treatment taken, names
of medications, tests done, results of the under table1
Table 1: Additional disclosures
Exact diagnosis Details of treating Date of Date of last Details of List of medications Details and date of Provide details of any Details related
doctor/ surgeon (Name, first diagnosis consultation current symptoms being consumed hospitalization and further consultation / to Question 2
qualifications, contact no.) currently surgery done surgery planned
Declarations
I/we fully understand that this declaration and all other details specified by me shall be the basis on which this insurance upon my life is being given by Future Generali India Life Insurance
Company Limited through the Group Policy issued to Master Policyholder
I/ we declare that I/we have answered the question in the form and have fully understood the nature of the questions and the importance of disclosing all material information while answering
questions. I/ we further declare that the answers given by me/ us to all the questions in the form and the information given to the medical examiner of the Company as to the state of health and
habits are true and complete in every respect and that I/ we have not withheld any material information or suppressed any material fact. I/ we have made no statements to the Group Master
Policy Holder, medical examiner, or any other person associated with the Company which in any way modifies the answers and statements on this application. I/ we undertake to notify the
company of any change in the state of health or as to occupation subsequent to the signing of this form and before the acceptance of the risks by the company.
I/ we hereby authorize Company to conduct screening / confirmation/ reconfirmation of overall status of the life to be assured including the health status through medical examinations. I/ we
hereby give my/ our consent to undergo medical test as per Board approved underwriting guidelines of the Company. The company reserves the right to accept, decline or offer alternate terms
of this application.
I/ we do hereby declare that the foregoing statements and answers are true and complete in every particular and agree and declare that these statements and this declaration along with the
proposal for insurance shall be basis of the group insurance contract, and that if any untrue averment be contained therein, the certificate of insurance issued to me shall be cancelled
immediately by the Company in accordance with Section 45 of Insurance Act, 1938.
I understand that the Company will not be on the risk until it has accepted the proposal, the premium paid and communication of the acceptance has been given to me in writing. Risk beyond
free cover limits will commence only after it is exclusively accepted premium paid and decision of acceptance communicated to me.
In order to enable the company to assess the risk under my proposal and any time thereafter , I/We hereby authorise my/our past and present employer/ business associates/medical
practitioner /hospital any medical source/any Life and Non-Life insurance company /or any organisation to release to the company and the company to release any medical source /any Life
and Non-Life insurance company, such details and provide such records of my employment / business or other details as may be considered relevant. I/We authorise the Company to store, use
and share information contained in the proposal form including the medical records with its partners, associates, consultants, any government and / or Regulatory authority under any Statute /
or Insurance Repository, or as required under any Rules and /or Regulations as may be applicable for the time being in force or with any other entity with respect to servicing of my policy.
Signature Date D D M M Y Y Y Y
If the account holder signs in vernacular or affixes his/her thumb impression, he/she has to affirm having read and understood the following declaration by affixing his/her
signature/thumb impression below the same.
For Electronic Proposal Form:

This proposal form has been electronically authenticated through an OTP received on Mobile Number on at AM /PM
Declaration by Group Administrator / Group Master Policy Holder at the time of collecting the enrolment form.
I hereby declare that I have seen in person the member to be insured. I do not observe any physical or mental deformity of the member to be insured and the member can be covered
for insurance.
Name Employee / Staff Code Signature Date D D M M Y Y Y Y
Declaration to be given in case the Enrolment/ Proposal Form is signed in Vernacular or the Life to be assured is Illiterate
I have been explained the terms and conditions of this policy and I am agreeable to the same and am affixing my signature or Left Thumb Impression (LTI) herein below to affirm the same.
I have explained the contents of this enrolment/proposal form to the member to be insured and ha ve ensured that the contents have been fully understood by him/her. I have accurately
recorded the member’s responses to the information sought in this enrolment/proposal form and I have read out the responses to him/her and he /she has confirmed that they are correct.
Signature of Declarant Signature or LTI of member to be insured

(Sales Intermediary)
Name of Declarant Date D D M M Y Y Y Y
Address of Declarant
Place Date D D M M Y Y Y Y
Section 45 of the Insurance Act, 1938 as amended from time to time states:
1. No Policy of Life Insurance shall be called in question on any ground whatsoever after the expiry of 3 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 3 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.
For further information, Section 45 of the Insurance laws (Amendment) Act, 2015 may be referred.
Section 41 of the Insurance Act, 1938 as amended from time to time states:
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 lakh rupees.
Future Group’s, Generali Group’s and IITL Group’s liability is restricted to the extent of their shareholding in Future Generali India Life
Insurance Company Limited. (CIN: U66010MH2006PLC165288) | ARN: FG-L/PD/MKTG/EN/PPF-001PF | Regd. & Corporate Office:
Indiabulls Finance Centre, Tower 3, 6th Floor, Senapati Bapat Marg, Elphinstone Road (West), Mumbai 400013 | Fax: 022-4097 6600,
Email: [email protected] | Call us at 1800 102 2355 | Website: life.futuregenerali.in

Member Enrolment Form-GTL-without Addendum-19 Nov 2018

Uploaded by

Copyright:

Available Formats

Member Enrolment Form-GTL-without Addendum-19 Nov 2018

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Member Enrolment Form-GTL-without Addendum-19 Nov 2018

Uploaded by

Copyright:

Available Formats

MEMBER ENROLMENT FORM FOR

FUTURE GENERALI GROUP TERM LIFE INSURANCE PLAN (UIN 133N003V03)

To be filled in by Member to be insured

Health details of Proposed Insured (Please use ü in boxes to indicate choice)

For Electronic Proposal Form:

Name Employee / Staff Code Signature Date D D M M Y Y Y Y

Signature of Declarant Signature or LTI of member to be insured

Name of Declarant Date D D M M Y Y Y Y

You might also like