NRI Questionnaire Ver 11 - 240211 - 124258

NRI/ PIO/OCI/ Foreign National Questionnaire- 2018
Proposer name :_____________________

Life Assured name :______________________
Application number :____________________
Questions Proposer Life Assured ( to be filled if different than
Proposer)
1 Foreign Residence address along with
current country name
2 Have you changed country in past 12  yes  No  yes  No

Months? If yes, please mention the name(s)
of the country(s) along with date. If yes, pl provide details ____________________ If yes, pl provide details ________________
3 Nationality Name of Country ____________________ Name of Country ____________________

4 Residential Status  NRI PIO  OCI  Foreign National  NRI PIO  OCI  Foreign National
5 Have you changed nationality ? If yes ,
please provide previous nationality
6 Duration of stay abroad
7 Purpose of stay abroad
8 Date of arriving in India
9 Expected date of leaving India after recent
visit
10 Country (s) of tax residence 1. NA
(if taxes are/are also filed outside India)- 2.
mention if more than one country 3.
11 Tax identification no (TIN) - mention if more 1. NA
than one country has issued TIN . 2.
3.
For country not issuing TIN , mention  VISA /
 Residence / Work Permit Number
12 Do you earn any income in India ?  yes  No NA
Submission of PAN card copy is mandatory if
Indian earned annual income exceeds INR 2.5 lakh If yes, please state annual income earned in India
__________________________INR / annum
13 Do you intend to travel to any other country

as part of your job/business? If yes, please  yes  No  yes  No
state country(s) and stay duration
_________________________________ ________________________________
14 Type of bank account for premium

 NRE  NRO  Resident  NRE  NRO  Resident
remittance
15 Is there any prosecution/legal proceeding  yes  No  yes  No
initiated in the past or going on against you
presently before any judicial forum,/ authority _________________________________ _____________________________
in the country of your residence ?
16 Name and address , phone no. of your NA
physician in your country of residence ( if you
are on treatment)
Declaration by the Proposer & Life Assured:

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 part of my application for life assurance with Canara HSBC Life Insurance
Company Ltd (the ‘Company’) and that failure to disclose any material fact known to me may invalidate the contract.
I am not restricted /prohibited from proposing for this policy of insurance under the laws of any country that I am subject to. I understand that my purchase of a policy
of insurance from the Company may create legal, tax or other financial/ reporting obligations for me under the laws of the country of which I hold citizenship or reside
in. I shall be solely responsible for undertaking and fulfilling any obligations that I may have under the laws of such country/ies and shall not hold the Company liable
under any circumstance in the event of a default on my part in fulfilling the said obligations. I acknowledge and agree that any information provided by the Company
is not intended to provide legal, accounting or tax advice and I shall not rely on the same in this regard. I will seek independent professional legal, accounting and
tax advice prior to the purchase of the policy of insurance from the Company, where necessary.
Date & Place: Signature of Proposer- :
Date & Place: Signature of Life Assured ( if different than the proposer) : -
Declaration in case Proposer/ Life Assured signs in Vernacular / Uses Thumb Impression:
I have read out and fully explained the contents of the questionnaire and he/she has understood the same. I have truthfully recorded the replies given by the
Proposer and that the Proposer has affixed his/her signatures/thumb impression above after fully understanding the contents hereof.
UW/NRQCHOICE/Ver. 1.0
Date & Place: Name and Signature of Declarant :-
Canara HSBC Life Insurance Company Limited (formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance
Company Limited) IRDAI Regn. No. 136
UW/NRQCHOICE/Ver. 1.0

NRI Questionnaire Ver 11 - 240211 - 124258

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NRI Questionnaire Ver 11 - 240211 - 124258

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NRI/ PIO/OCI/ Foreign National Questionnaire- 2018

Proposer name :_____________________

2 Have you changed country in past 12  yes  No  yes  No

3 Nationality Name of Country Name of Country

13 Do you intend to travel to any other country

14 Type of bank account for premium

Declaration by the Proposer & Life Assured:

Date & Place: Signature of Proposer- :

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