PROPOSAL FORM FOR SINGLE LIFE

Please fill this form in BLACK INK & CAPITAL letters only.
For office use only
LOB / Agent Code Agent / AFSM Name

AFSM Code
Opp ID
Bank Branch Source Proposer’s Photograph
LIM /
Bank A/C (Please affix color photograph)
CSR Code
Cafos Code SP/ POS Code
PAN of POS Other document of
Agent POS Agent
IN UNIT-LINKED INSURANCE POLICIES (ULIPs), THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.
IMPORTANT GUIDELINES: 1) Insurance is a contract of utmost good faith between the Insurer and the Insured. The Proposer and the Life to be Assured are
required to disclose all facts in response to the questions in this application form. 2) Any cancellation/alteration is to be signed by Proposer/Life to be Assured as
applicable. 3) For adding nominee(s) or assignee to the policy please refer to the servicing forms available on our website.

I/we understand the importance of disclosing all material information and confirm that I/we shall share details which are true and correct, failing Signature / Thumb
which the company reserves the right to cancel the policy and/or repudiate any claims under the policy and initiate appropriate action. impression of Proposer

I. Generic details
Existing Policy Owner, Kindly enter policy number / client id Policy No Client ID

Is this policy self proposed? Yes No If No, please answer the following details Type of Proposer Individual Non-individual
Relationship with Type of Employer
Keyman Trust HUF MWPA
Life to be Assured Proposal Employee

II. Proposer/Policy Owner Details (Please fill in details of Life to be Assured if same as Proposer)
First Name Middle Name Last Name
Full Name

Father Name

Mother Name

Spouse Name
Communication Address of the Proposer (Address to which policy document will be dispatched)
LINE 1

LINE 2

LANDMARK CITY

STATE

COUNTRY Pin Code

Permanent Address of the Proposer (If different from the above address)
LINE 1

LINE 2

LANDMARK CITY

STATE

COUNTRY Pin Code

Mobile*+ ( Country Code

( *Receive alerts through SMS
Landline+ ( STD/ISD
(
*Receive communication via e-mail
Email ID*

DOB D D M M Y Y Y Y Gender Male Female Transgender Nationality Indian Non Indian

Marital Status Unmarried Married Widow(er) Divorced Resident Status Resident NRI PIO Foreign National
th th
Education Post Grad. Graduate Diploma 12 pass 10 pass Below10
th

Self
Occupation Salaried Professional Student Housewife Retired Others (Please Specify if Others)
Employed
Industry Import/ Scrap Real Stock
Jewellery Mining Shipping Agriculture (Please Specify if Others)
Type Export Dealing Estate Broking
Organisation Partner/ Section 25
Govt. Pvt. Ltd. Public Ltd. Trust HUF Society Others
Type Proprietor Company
Name of the
Income(Annual)
Org./Business
Are you a Politically Exposed Person Do you wish to share portfolio/fund details (Default value will be taken as
(Proposer/Life to be Assured)? Yes No Yes No No if left blank.)
with your advisor/ agent?
Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, example, Heads of State or of Governments, senior
politicians, senior government / judicial / military officials, senior executives of state owned corporations, important political party officials, etc., including their family members and close relatives.
Address Proof* (Proposer) Other Document
* Residential proof only
Identity proof Identity proof
(Proposer) Number
Identity proof PAN Income Proof
Expiry Date* D D M M Y Y Y Y (Proposer) (Proposer)
*Applicable only for Passport and Driving licence (include form 60 if PAN is not available)
Existing KYC number (Central KYC registry number, if available)
1
III. Proposer/Policy Owner Electronic Insurance Account (eIA)
1. Do you wish to open Electronic Insurance Account and convert your policies into electronic policies : Yes No (Default value will be taken as No if left blank.)
2. Select your preferred insurance repository to NSDL Insurance CDSL Insurance CAMS Repository Karvy Insurance Repository
open Electronic Insurance Account: Repository Repository Limited Services Limited Limited
3. Electronic Insurance Account (eIA)
4. Do you wish to convert your ICICI Prudential policies into electronic policies : Yes No (Default value will be taken as No if left blank.)
Note: Please note that if you already have an existing Electronic Insurance Account then new eIA will not be created and policies will be credited into your existing electronic insurance account if opted
for in point no.3. Also eIA will be opened only if Email, Mobile and PAN is provided in the application form.

IV. Details of the Life to be Assured (Please fill section II only if Life to be Assured is different from Proposer)

Full Name (Leave a blank space between First and Last Name) Mr. Ms. Dr.

F I R S T L A S T
DOB D D M M Y Y Y Y Gender Male Female Transgender Nationality Indian Non Indian

Marital Status Unmarried Married Widow(er) Divorced Resident Status Resident NRI PIO
th th
Education Post Grad. Graduate Diploma 12 pass 10 pass Below10 th

(Other For eg. Builder, Diamond

Occupation Salaried Professional Self Employed Student Housewife Retired Others Merchant, Scrap Dealer)

Name of the Org./Business Income(Annual)

V. Personal Details of the Life to be Assured (This section need not be filled if you have opted for only zero sum assured product)

Simple Medical Questionnaire

(SUPPRESSING FACTS OR GIVING WRONG INFORMATION WILL ADVERSELY IMPACT PAYMENT OF YOUR CLAIM)
1. Have you ever suffered or are suffering from or been advised to undergo regular medical consultation/ investigations or treatment including Yes No
hospitalization for:
 Cancer or tumor of any kind  Lung related ailments  Heart related aliments

 HIV/ AIDS related ailment  Liver related ailments  Diabetes

 Mental or Nervous disorders related ailments  Kidney related ailments  Hypertension

 Any illness requiring leave from work or hospitalization for more than 7 consecutive days or any disability lasting more than 90 days in the last 10 years

2. Have any proposals on your life / application for reinstatement ever been postponed or declined.

Detailed Medical Questionnaire

SUPPRESSING FACTS OR GIVING WRONG INFORMATION WILL ADVERSELY IMPACT PAYMENT OF YOUR CLAIM
1. Age Proof Passport Driving Licence School/ College Certificate Others Specify
c. Do you consume or have consumed any of the following?
2. a. Height (Ft/ Inches) cms
Substance
Yes/No Consumed as Quantity No of Years
Consumed
b. Weight (Kilograms)
Tobacco Y/N Cigar/Cigarette/Beedi/Gutka Quantity/Day

Alcohol Y/N Beer/Wine/Hard Liquor Quantity/Week

Any Narcotics Y/N

3. Lifestyle details of the Life to be Assured Yes No

a. Is your occupation associated with any specific hazard or do you take part in activities or have hobbies that could be dangerous in any way?
(e.g. occupation- chemical factory, mines, explosives, radiation, corrosive chemicals & hobbies – aviation other than as a fare paying passenger, diving,
mountaineering, any form of racing etc.)
b. Are you employed in the armed, para military or police forces?
(If yes, please provide Rank, Department/Division, Date of last medical & category after medical exam)
4. Family details of the life to be assured(include parents/sibling) Are any of your family members suffering from/have suffered from/have died of
heart disease, Diabetes Mellitus, cancer, or any other hereditary/familial disorder, before 55 years of age? if yes please provide details below,
5. Have you lost weight of 10 kgs or more in the last six months?
6. Do you have any congenital defect/abnormality/physical deformity/handicap?
7. Have you undergone or been advised to undergo any tests/investigations or any surgery or hospitalized for observation or treatment in past?
8. Did you have any ailment/injury/accident requiring treatment/medication for more than a week or have you availed leave for more than 5 days
on medical grounds in the last two years?
9. Have you ever suffered or been diagnosed with or been treated for any of the following? None of the below

Hypertension/High BP/high cholesterol Chest pain/Heart attack/any other heart disease or problem
Undergone angioplasty, bypass surgery, heart surgery Diabetes/High blood sugar/sugar in urine
Asthma, Tuberculosis or any other respiratory disorder Nervous disorders/stroke/paralysis/epilepsy
Any Gastro intestinal disorders like Pancreatitis, colitis etc. Liver disorders/Jaundice/Hepatitis B or C
Genitourinary disorders related to kidney, prostate, urinary system Cancer, Tumour, Growth or cyst of any kind
HIV infection/AIDS or positive test for HIV Any blood disorders like anaemia, Thalassemia etc
Psychiatric or mental disorders Any other disorder not mentioned above

10. To be answered by female lives only

a. Have you ever suffered/are suffering from or have undergone any investigation or treatment for any gynecological complications such as ,
disorder of cervix, uterus, ovaries, breast, breast lump/cyst etc.?
b. Are you pregnant at present?
If yes, please mention number of weeks _________________

Question number Details if marked 'Yes’

Please submit previous medical reports (if any), as receipt of these reports would help us in faster assessment of the health of the Life to be Assured.
Please attach a separate sheet in case the space is inadequate.

2
VI. Previous Policy Details
1. Details of Life Insurance/Mediclaim/Health/Personal Accident policies of the Life to be Assured held/applied with ICICI Prudential/other companies.
(Have any such proposals on your life / application for reinstatement ever been accepted with extra premium, postponement, decline, withdrawal, non
completion, been offered on modified terms. If yes, please provide details.) $ Mention year of Lapse/Revival applied for

Year of Basic Sum Assured Annual Premium Base Plan / Medical In Force/
Policy / Proposal No. Company Name $
Issue / Application (in `) (in `) Rider Decision Policy Lapsed
Y/N

Y/N

2. If Life to be Assured is a student/housewife, please provide insurance details regarding parents/husband/siblings.

(Please attach a separate sheet for multiple policies if required)
Total Sum Assured of all Inforce Policy no and Name of the Company Husband’s/Parent’s
Life Insurance policies Occupation/Income

VII. Particulars Of Product Applied For

1. Objective of taking this policy Saving Protection Both Others Please specify

2. Mode (for regular/limited premium payment plan) Yearly Half- Yearly Monthly

2a. Mode (for renewal premium) Credit Card Direct Debit ECS Cheque/DD Cash Others Please specify

Product Name
Policy Term Premium Payment GMB/GSB# Sum Assured Modal Premium
3. Product (in yrs) Term(in yrs) (in `) (in `) (in `)
Details

#
Guaranteed Maturity Benefit

3a. Benefit Payout Option: Lump sum Income Increasing income 3b. Accidental Death Benefit:

3c. Accidental Death Benefit coverage period: 3d. Accelerated Critical Illness Benefit:
3e. Accelerated Critical Illness Coverage period:
3f. Plan option:

Rider Rider Term Rider Premium

4. Rider Sum Assured Modal Premium
Rider Name Payment Term
(Optional No. (in yrs)
(in yrs)
(in `) (in `)

with
Additional
Premium)

Total Annual Premium (in `) If you require Backdation, please mention date D D M M Y Y Y Y
(As mentioned on Electronic Benefit Illustration (EBI), inclusive of taxes) (Available with select plans only. Policy can be backdated only within the same financial year)
5. Annuity Plan Details* (Applicable only for Pension plans):
5a. Single Premium (Purchase Price): (in `) 5b. Annuity Amount to be paid (in `)
5c. Annuity Options (Please tick one option only in the appropriate box)
Product Name:
Annuity Option: Deferment Period (If applicable):

5d. Frequency of Annuity payments: Yearly Half-Yearly Quarterly Monthly

Secondary Annuitant Name (Leave a blank space between First & Last Name) Mr. Ms. Dr.

Secondary Annuitant DOB: D D M M Y Y Y Y Gender of Secondary Annuitant: Male Female Transgender

Relationship with Primary Annuitant:

*The Policyholder will have to select the proportion of annuity to be received as a lump sum and the balance in the form of an annuity as described above. In case
you fail to select the annuity proportion at time of vesting, 100% of vesting amount will be annuitized.
6. Strategy & Fund Allocation (for ULIPs) Please select the proportion in which you wish to invest your premiums (%) as per the options available with the product chosen.
LifeCycle based LifeCycle based Fixed Target Asset Trigger Portfolio
6a. Please Select Portfolio Strategy Portfolio Strategy Portfolio Strategy 2 Portfolio Strategy Allocation Strategy Strategy 2

Fixed Portfolio Strategy

Easy
Active Asset Multi Secure Value Easy Easy
Maximiser Maximise Multi Cap Money India Growth Focus 50 Retirement
Allocation Cap Opportunities Bluechip Income Opportunities Enhancer Retirement Retirement Total
V India Fund* Balanced Market Fund Fund SP
Balanced Growth Fund Fund Balanced Secure
Balanced

100%

*Please check the Fund and Portfolio Strategy applicability for the applied product.
Note: For the Segregated Fund Identification Number (SFIN) please refer the product brochure/ leaflet or the Electronic Benefit Illustration. You may also logon to our website iciciprulife.com
for the same. If the Above mentioned proportions are not clear, values from Signed Electronic Benefit Illustrations will be considered.

6b. I would like to opt for Automatic Transfer Strategy Yes No

From To ( any one) Amount ` (per month) Transfer Date

1st of the Month th

15 of the Month

7. I would like to opt for Systematic Withdrawal Plan Yes No

st
Payout Start Year: Payout Date: 1 of the Month th
15 of the Month

3
VIII. Nominee Details (To be filled only if Proposer & Life to be Assured are same. Enter child details if applied for SmartKid plans)
Full Name (Leave a blank space between First and Last Name)
F I R S T L A S T
Relationship with
DOB D D M M Y Y Y Y Gender Male Female Transgender
Life Assured

IX. Appointee Details (If Nominee is less than 18 years, Appointee is mandatory. Appointee MUST be above 18 years of age)
Full Name (Leave a blank space between First and Last Name)

F I R S T L A S T
Relationship with
DOB D D M M Y Y Y Y Gender Male Female Transgender
Nominee

X. Particulars Of First Premium Deposit

1. Mode of deposit Cash Cheque/ DD Credit Card Others

2. Amount (in `) 3. Bank 4. Cheque/DD No.

5. Is the premium paid by a person other than Proposer (If yes, please submit third party declaration) Yes (Tick if applicable, default value No)

6. Source of Funds Salary Business Income Sale of Assets Inheritance Others Specify
Note: 1. Cheque/ DD should be drawn in favour of “ICICI Prudential Life Insurance Co. Ltd.” only. Please mention application no. and name of the proposer behind the cheque/ DD. 2. In the
event of non-realization of first premium deposit, the policy, if issued, shall be treated as cancelled/void from inception. 3. Incase of non-acceptance/ withdrawal of this application for
insurance, the company shall return the first premium deposit without any interest and after deducting the expenses incurred on the medical tests/ examination. 4. Please note that a copy of
PAN card or Form60/61 as applicable shall be required for premium payments in cash of ` 50, 000/- or more. You are requested to pay cash only at the authorized collection points and not to
advisor or employee. The company will not be responsible for any loss in this regard. 5. Please submit a cash authority letter along with the cash if you are depositing the cash through a third
party. 6. Payments made through credit cards can be accepted only if the card is issued in the name of the relevant proposer/ policy holder.

XI. Payout Mode (Choose any one mode only)

Mode selected would be used by the company to make payout(s) to the Proposer. Payout would be in accordance and subject to the terms and conditions of the policy.

1. Mode of deposit ECS Direct Credit (Select Banks only) NEFT 2. Account Type Current Savings

3. Bank Name 4. Bank Branch

5. Account Number 6. MICR Code

7. IFSC Code
Note: 1. Please provide a cancelled copy of your cheque if any of the above payout option is selected. 2. In case of non credit to my bank
account with/ without assigning any reasons there of or if the transaction is delayed or not effected at all for reasons of incomplete/
incorrect information, I would not hold ICICI Prudential Life Insurance Co. Ltd. responsible. 3. Further, the Company reserves the right __________________________________
to use any alternative payout option in spite of opting for Direct Credit option. Signature of Proposer

XII. DECLARATION & AUTHORIZATION

I/We declare that I/we have answered the questions in the proposal form and have duly signed it after understanding its contents. I/ We have fully understood the nature of the questions including
health related questions and the importance of disclosing all material information while answering such questions. I/We declare that the answers given by me/us to all the questions in the proposal
form and the information given to ICICI Prudential Life Insurance Co. Ltd. as to the state of health and habits of the life/lives to be assured 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 statement to the Insurance Advisor, Medical Examiner or any other person associated with the Company
which in any way modifies the answer given by me/ us in this application form. I/We undertake to notify the Company of any change in the information given by me/ us in the proposal form with
respect to the Life/ Lives to be Assured subsequent to the signing of this proposal form and before the receipt of the policy document. I/We also understand that the the premium and the benefits
payable under the Policy are subject to variation/ taxes/ duties/ charges in accordance to applicable laws. I/We confirm that all premiums will be paid from bonafide sources. I/We hereby authorize
ICICI Prudential Life Insurance Co. Ltd. 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/our consent to undergo HIV1/2 test. I/We am/are aware that this test is only for screening purpose and not confirmatory for HIV/AIDS.
I/We hereby authorize ICICI Prudential Life Insurance Co. Ltd. to mail all service related communications to the email id as mentioned in the application form (applicable only if email id provided).
The Company reserves the right to accept, decline or offer alternate terms on my/our proposal for Life/Health Insurance. In order to enable the Company to assess the risk under this proposal and
any time thereafter, I/we hereby, authorize the past and present employer(s)/business associates/medical practitioner(s)/hospital and medical source/any life and non-life insurance Company to
provide the records of employment/business or other details as may be considered relevant. I/we agree and authorize the Company, for the purpose of processing of this Proposal or servicing of
the resulting policy, to verify/share relevant information provided herein on confidential basis within ICICI group and/or third party agencies. This application form shall be a part of the life insurance
policy contract, in case of its acceptance by the Company. I hereby consent to receiving information from Central KYC Registry through sms/ email on the above registered number/email address. I
understand that in case of fraud or misrepresentation by me/us, the policy shall be treated by the Company in accordance with Section 45 of the Insurance Act, 1938 as amended from time to time.

Signature / Thumb impression

Date D D M M Y Y Y Y of Life to be Assured
Signature / Thumb
impression of Proposer (TO BE SIGNED ONLY
IF DIFFERENT
Place
FROM PROPOSER)

XIII. DECLARATION
(If signed in Vernacular language/ If you have affixed a Thumb impression above/ proposal form is filled by person other than Life to be Assured or Proposer)

Applicable where the Proposer is illiterate or is suffering from disability due to which writing is restricted or where the Proposer has signed in vernacular
language. (Note: The below must be witnessed by someone other than the advisor /employee of the Company)
I, (full name of the declare) ______________________________ hereby declare that I have explained the contents of the proposal form to the Life to be Assured/
Proposer in _________ language and that I have read out the answers to the questions explained by me to the Life Assured/ Proposer and that the Life to be
Assured/ Proposer has/ have put his/ her thumb impression after fully understanding the contents thereof.

Date D D M M Y Y Y Y
Signature of Declarant
Place

I/We certify that the product applied for by me/us and the contents of the proposal form have been clearly explained to me/us and I/we have fully understood
them. I/ We further certify that the replies in the proposal form have been recorded as per the information provided by me/us.

Date D D M M Y Y Y Y
Signature/ thumb impression of Life to be Assured/
Proposer signing in vernacular language
Place

4
 XIV. THE INSURANCE LAWS (AMENDMENT) ACT, 2015
Section 41 Prohibition of rebates: (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.
Section 45 Policy not to be called in question on ground of mis statement after three years: (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 specially 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 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 mis-statement or suppression of a material fact, and not on the 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 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.”

Application No.

ACKNOWLEDGEMENT SLIP
Received from ___________________________________________________________________________________________________________________________________
the proposal for Life Insurance along with ` ___________________________ by way of cash/ cheque/ DD No./ credit card/ IVR/ Net banking ________________________
drawn on ________________________________________ at the __________________________ Branch of ICICI Prudential Life Insurance Company.

Date of cheque/ deposit

Instrument No.

Drawn on/ Issuing Bank

Plan name

Date received
Signature and Rubber stamp of Branch official
5
XV. Advisor’s Confidential Report (Mandatory for Advisor/AFSM to fill):
I hereby declare that the customer has understood the nature of questions in the proposal form and the importance of disclosing all the material information. I declare the facts disclosed in the
proposal form are true and correct to the best of my knowledge and belief. I confirm having verified the identity of the Proposer and Life Assured, source of fund and address of the customer and
the proofs submitted along with this form with the original documents.
2. How do you know the Proposer/
1. Nature of Work
Life to be Assured?
3. How long have you known the Proposer/ 4. Is the Proposer/Life to be Assured
Yes No If Yes Give Details
Life to be Assured? (yrs) related to you?
5. Income details of Proposer/
Give Details
Life to be Assured (` Per annum)
6. Personal Asset details: (A) House Owned Rented Co. Provided (B) Vehicle 4 Wheeler 2 Wheeler NA
7. General Health details of Life to be Assured as observed/ informed to you:
Physical Handicap/ Deformity Yes# Mental Retardation Yes# History of any Illness/ Surgery Yes# Medical Investigations done Yes#

If answer to any of the above questions is yes, please provide details ______________________________________________________________________________
8. Any other risk associated with Occupation, Sports Pursuit or Personal Habits of Life to be Assured/ Annuitant that could affect the risk in the insurance
proposal, please provide details ________________________________________________________________________________________________________________
9. Any other material information or facts as regards to the social/ financial status and the source of funds of the proposer which might have any adverse
impact on acceptance of the proposal, please provide details ____________________________________________________________________________________
National / State level office bearer of
10. Is the Proposer a: Judge Member of Parliament Member of state legislature
political party
#
( Tick if applicable, default value No)
Other Remarks: Material disclosure pertaining to any adverse habit, health or income inconsistency of the prospect

Date :
Signature of the Advisor/AFSM Name and Code No. of the Advisor/AFSM

Place :

FREELOOK PERIOD (15/30 day refund policy):

• The Freelook period starts from the date you receive the policy document. It is 15 days in case of non Distance marketing policies and 30 days in case of Distance marketing
policies.
• During this period you are required to go through documents sent to you in the welcome kit. If you are not satisfied with the same, please return the policy document to the
Company along with a request for cancellation within the period mentioned above.
• We will cancel the Policy and return the premium after deducting the stamp duty, expenses borne by the Company on medical examination, if any and fluctuation in NAV.

PLEASE NOTE:
In case of payments by Cheque / Demand Draft, please draw the instrument in favour of “ICICI Pru Life Application No. ________________________”
1. Any Cheque / Cash / Demand Draft payment made shall be deemed to be received by ICICI Prudential Life Insurance Co. Ltd. only when the same has been received by any
office or collection point and after an official receipt is issued by the Company.
2. Should you choose to pay premium by Cash, you are advised to do so only at the nearest ICICI Prudential Life Insurance Co. Ltd. Branch or its authorized collection points. Handing
over cash to any Advisor / Employee is solely at your own risk and the Company shall in no way be held responsible for any loss in this regard.
3. This acknowledgment slip does not in any way communicate acceptance or commencement of risk under the application submitted by you. This is only an
acknowledgment slip and is not the premium receipt. This acknowledgment slip should not be used for Income Tax purposes.
4. The premium receipt shall be issued once the Company accepts the risk on your life and the amount deposited is applied to your policy as premium.
5. In case you do not receive the Policy Document within 17 days of completing all your requirements, please contact us on our customer service helpline.

CONTACT US

Visit us at Call us on: Write to us at our E-mail us at

www.iciciprulife.com 1860 266 7766* Communication Address [email protected]
Call Centre Timings: 10 am. to 7 pm. IST Monday to Saturday, except National holidays. *When calling our customer service, please do not prefix "+" or
"91" or "00" before the number. International Customers can call +91-22-6193 0777. Charges as applicable.
Communication Address: ICICI Prudential Life Insurance Company Limited, Ground Floor & Upper Basement, Unit No. 1A & 2A, Raheja Tipco Plaza,
Rani Sati Marg, Malad (East), Mumbai- 400097. 6