CLIENT REGISTRATION FORM

Applicant Details
Applicant Name

Middle Name

Last Name

PAN No.

Mobile No.

Email

Date of Birth D D M M Y Y Y Y

Gender Male Female Others Status Resident Indian NRI

Marital Status Single Married Widowed Divorced Separated

Father/Spouse Name

Tax Status
Tax Status Individual NRI- HUF NRI-Repatriable(NRE) NRI-Non-Repatriable (NRO)
NRI-on behalf of minor NRI-Other Sole Proprietorship On behalf of minor

E-Insurance Account Number:

[If you already have E-Insurance Account, please mention your account number here]

Correspondence Address

Address Line1

Address Line2

Address Line3

Landmark

City

Pin Code State Country

Permanent/Registered Address

Address Line1

Address Line2

Address Line3

Landmark

City

Pin Code State Country

NJ INSURANCE BROKERS PRIVATE LIMITED (CIN: U67200GJ2002PTC041664)

Block No.502, 2nd Floor, 'B' Tower, Udhna Udyog Nagar Sangh Commercial Complex, Central Road No. 10,
Udhna, Surat – 394 210, Gujarat. Contact Number: 0261 4025500 | Email: [email protected] | Website: www.njinsure.in 1
Registered with IRDA vide Certicate No.407, Licence Code No. DB447/09, valid upto 28-02-2020.
 CLIENT REGISTRATION FORM

Political exposure Yes No

Occupation Type Private / Public sector Govt service Business Professional Agriculture

Retired House wife Student Others (Specify)

Annual Income Range From ______________ To ______________ ` in Lacs

Total Net worth ` As on D D M M Y Y Y Y

Declaration:
I/we hereby declare that the details furnished above are true and best of my/our knowledge and belief and I undertake to inform you of
any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting,
I am/we are aware that I/we may be held liable for it.

Note:
NJ IndiaInvest Private Limited ("NJ India") is the agship company of NJ India Group. It is one of the leading distributor of Financial & Investment
Products like Mutual Funds, Real Estate, Fixed Income Products and Capital market products.

NJ India has an online access platform namely "Client Desk" which is a single window access tool for all the above products held by its Clients.

As you are a customer of NJ Insurance Brokers Private Limited ("NJIB") and you own certain insurance policies, we would be sharing your insurance
portfolio related information with NJII. The information includes soft copies of your proposal form and policy copy, renewal notice and Claims related
data.

To facilitate your insurance portfolio information on your client desk, NJIB has entered into an information sharing arrangement with NJ India.

Further to inform you that, access to this information will be available with your advisor and concerned employees of NJ India also.

In case you do not want us to share the above information, please mail us on [email protected].

NJ INSURANCE BROKERS PRIVATE LIMITED (CIN: U67200GJ2002PTC041664)

Block No.502, 2nd Floor, 'B' Tower, Udhna Udyog Nagar Sangh Commercial Complex, Central Road No. 10,
Udhna, Surat – 394 210, Gujarat. Contact Number: 0261 4025500 | Email: [email protected] | Website: www.njinsure.in 2
Registered with IRDA vide Certicate No.407, Licence Code No. DB447/09, valid upto 28-02-2020.
 ONLINE SALES TERMS & CONDITIONS

1. NJ Insurance Brokers Private Limited, a company registered under the provisions of the Companies Act 1956 and having its registered ofce at Block
No.502, 2nd Floor, B Tower, Udhna Udyognagar Sangh Commercial Complex, Central Road No.10, Udhna, Surat – 394210, Gujarat (Hereinafter “NJIB”).
NJIB is also registered with Insurance Regulatory and Development Authority of India as an Insurance Broker bearing License No 407 under the applicable
IRDA Regulations for Insurance Brokers.

2. NJIB owns and maintains its website “www.njinsure.in” and/or the mobile application for android and iphone users (hereinafter “Website”) to provide the
facility to its clients to access to the important information relating to insurance products offered by various insurers and to buy the insurance products and
renew the existing policies of the various insurance companies in India.

3. This Website is used exclusively for web aggregation and comparison of insurance products and online sale of insurance products offered by various
Insurers having arrangement with NJIB.

4. Before submitting the proposal to buy or renew any insurance policies on Website, the client agrees to carefully refer, read and understand the important
information relating to the insurance products offered by various insurance companies such as policy terms and features, premium details, cover details, etc.

5. The policy is issued by Insurance Company and not NJIB, which provides only online platform to buy various insurance products alongwith the premium
comparisons in compliance of the applicable IRDA guidelines.

6. The client agrees to provide necessary information for the purpose of buying or renewing the insurance products on Website. The client covenants that the
information submitted on Website is correct and adequate without concealing any material information. The proposals with incorrect or insufcient details are
entitled for rejection.

7. Only those insurance products will be available on Website for online sale to the clients which are permitted by IRDA and offered by Insurance Companies
for online sale through NJIB under an agreement.

8. The client acknowledges that Insurance Company has a right to consider the proposals for any insurance contracts in accordance with its underwriting
policies, rules and regulations as in force from time to time.

9. NJIB provides link to the website of the Insurance Companies for execution of sale of offered insurance products to the client using Website of NJIB.

10. The product details displayed on the Website are on the basis of the information received from the Insurance Companies, for which NJIB does not give any
guarantee or assurance of correctness, accuracy or tness thereof.

11. Premium:
a) The client can make the payment of premium by any mode permitted by Reserve Bank from time to time though the payment gateway used by insurers.
The premium will directly be credited to the concerned insurer's premium collection account and not through NJIB's bank account. NJIB does not accept
cash under any circumstances.
b) The client will receive the policy documents and premium receipt, on payment of agreed premium through electronic insurance policy or physical
insurance policy to his mailing address, as per the mode opted by him.

12. Disclaimer:
a) Any product offered or purchased through NJIB Website, is provided on an "AS IS" basis and without warranties of any kind, either expressed or implied,
directly or indirectly.
b) The client acknowledges and agrees that NJIB or NJIB’s directors, ofcers, employees, associates, service providers or other representatives shall not
be responsible or liable for any direct, indirect, incidental, consequential, special, exemplary, punitive or any other damages (including without limitation –
loss of prots, loss or corruption of data, loss of goodwill, work stoppage, computer failure or malfunction, transaction failure, transaction delay,
interruption of business, etc) under any contract, negligence, strict liability or other theory arising out of or relating in any way with the use of the Website.
c) The client acknowledges that the availability of Website, products, online facilities are subject to interruption for reasons which are beyond NJIB's
reasonable control.
d) NJIB does not represent or warrant that the Website will be uninterrupted, complete, accurate, authenticate, timely, updated, compatible, reliable, relevant
or error-free. NJIB has made appropriate efforts to ensure Website are free from defects, viruses, trojans, harmful components and that any defects will
be corrected as deemed appropriate by NJIB.

NJ INSURANCE BROKERS PRIVATE LIMITED (CIN: U67200GJ2002PTC041664)

Block No.502, 2nd Floor, 'B' Tower, Udhna Udyog Nagar Sangh Commercial Complex, Central Road No. 10,
Udhna, Surat – 394 210, Gujarat. Contact Number: 0261 4025500 | Email: [email protected] | Website: www.njinsure.in 3
Registered with IRDA vide Certicate No.407, Licence Code No. DB447/09, valid upto 28-02-2020.