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    Financial-Questionnaire - HSBC (SOW) - 240214 - 221958

    Uploaded by

    Wajid Mohd
    The document is a financial questionnaire for life insurance applicants. It requests information about the applicant and proposed insured's income, assets, existing insurance policies, and business details if self-employed. The applicant must declare that their answers are truthful and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Financial-Questionnaire - HSBC (SOW) - 240214 - 221958

    Uploaded by

    Wajid Mohd
    8 views1 page
    The document is a financial questionnaire for life insurance applicants. It requests information about the applicant and proposed insured's income, assets, existing insurance policies, and business details if self-employed. The applicant must declare that their answers are truthful and complete.

    Original Title

    financial-questionnaire_hsbc (SOW)_240214_221958

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    The document is a financial questionnaire for life insurance applicants. It requests information about the applicant and proposed insured's income, assets, existing insurance policies, and business details if self-employed. The applicant must declare that their answers are truthful and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    8 views1 page

    Financial-Questionnaire - HSBC (SOW) - 240214 - 221958

    Uploaded by

    Wajid Mohd
    The document is a financial questionnaire for life insurance applicants. It requests information about the applicant and proposed insured's income, assets, existing insurance policies, and business details if self-employed. The applicant must declare that their answers are truthful and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    FINANCIAL QUESTIONNAIRE (Online)

    (To be filled by the proposer/Applicant)


    ProposalNo:
    a. Full name of Life to be Insured:
    b. Full Name of Proposer:

    c. Occupation: Self Employed Salaried Housewife Student Others (give details) _

    1. Please provide accurate information of the annual income of insured for last 3 years. Please tick the relevant source of information:
    IT Returns Computation of Income Audited individual accounts Self Assessment

    Source of Income FY Document FY Document FY Document


    submitted (Yes/No) submitted (Yes/No) submitted (Yes/No)

    Salary

    Business

    Rent from Property

    Agricultural Income

    Investment Income

    Other sources
    (pls. specify)
    Total Income

    2. Please give details of all existing & applied covers with other Life Insurers on all family members:
    Relation with Type of Policy and Policy Year of Annualized
    Name of Insurer Sum Assured
    Proposer no. Issue Premium

    3. Please estimate the value of your personal Assets and Liabilities (Net worth):
    Assets Liabilities
    Property Loans
    Mutual Fund/ Equity Mortgages
    Bank Deposits, Company Deposits Business Loans
    Others (Pls. specify) Others (Pls. specify)
    Total Assets Total Liabilities

    4. BUSINESS DETAILS (to be completed by Self Employed Individuals only):


    Name of the Company/Partnership Firm:
    Commencement Date of the Business: _ _
    Proposed Insured’s Ownership in the Co.: Invested Equity in the Company: Rs _ Percentage of Ownership:
    Main Duties of the Proposed Insured in the Co.:

    Declared Profits of the Company as per audited A/Cs

    Year Year Year

    Rs. Rs. Rs.


    Declaration by the Proposer:
    I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information that may
    influence the assessment or acceptance of this application. I agree that this form will constitute a part of my application f or life assurance with
    Canara HSBC Life Insurance Company Limited (formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited)
    and that failure to disclose any material fact known to me may invalidate the contract.

    Date & Place: Signature of the Proposer:


    Declaration in case Life To Be Assured signs in Vernacular / Thumb Impression:
    I have read out and fully explained the contents of the questionnaire and he/she has understood the same. I have truthfully r ecorded the
    replies given by the proposer and that the proposer has affixed the signatures/thumb impression above after fully understanding the contents
    thereof.

    Date & Place Name and Signature of Declarant

    UW/FQCOONLINE/Ver.1.0 Internal Page 1

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