Application No: P03319158

Proposal Form
UNDER UNIT LINKED INSURANCE PLANS, INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.THE UNIT LINKED INSURANCE PRODUCTS
DO NOT OFFER ANY LIQUIDITY DURING THE FIRST FIVE YEARS OF THE CONTRACT.THE POLICYHOLDER WILL NOT BE ABLE TO SURRENDER OR WITHDRAW THE
MONIES INVESTED IN UNIT LINKED INSURANCE PRODUCTS COMPLETELY OR PARTIALLY TILL THE END OF THE FIFTH YEAR.
For Branch Sales Use Only
LG/Agent Code DB163995 Branch Code B7013 Branch Manager Code
(LG code to be written for Banca, Agent Code to be written for Agency.)

BDM/RM Code 1005806 Channel Code BAZH0003 BDM Mobile No. 7400432631

Bancassurance / Agency / Broker / Corporate Agency / Direct Sales / Marketing Associate, Any Others(pls specify)

Important Guidelines: 1.This form is to be filled by the proposer in BLOCKLETTERS in black / blue ink or to be filled electronically and leavea space blank between each part
of the name. 2.If the Proposer/ Life to be Assured is unable to fill the form due to inability to read or understand the language, the help of a person other than the advisor/ our
employee / insurance intermediary may be used.(Refer to declaration for signing in vernacular language or for uneducated / illiterate persons) 3.Before filling up the form please
read the sales literature to understand the features, benefits, advantages and terms and conditions of the product. 4.If the space provided in the form is not sufficient for providing
details, please attach separate sheets signed by the Proposer / Life to be Assured. 5.All details should be filled completely including email ID, mobile number, etc. 6.If annual
premium is equal to Rs. 50000 or more per customer by any mode of payment, a copy of PAN card and if annual premium is equal to or more than Rs.100000 per customer by
any mode of payment, income proof document needs to be submitted. 7.Customers are advised not to hand over the premium to IndiaFirst Life insurance advisors to meet the
premium dues(including initial premium). Customers are requested to visit the nearest IndiaFirst Life,Bank of Baroda & AndhraBank branch to deposit the premium
directly.Premium payment made to IndiaFirst Life insurance advisors is at the customer’s own risk.8.Encashment of cheque/ DDdoes notmean the policy has been approved and
the Company reserves the right to call for additional requirements subject to underwriting(if any) .9.While answering questions in the proposal formand providing any other
information in respect ofthe insurance,the Policyholder must make a full and frank disclosure of all material facts with respect to the questions available in proposal form.10.In
case the Proposer and Life to be Assured are two separate individuals, the proposal form will be signed by both.The life to be assured can sign only if he / she is 18 years or
above

Is the customer an employee of Bank of Baroda, Andhra Bank, eDena, eVijaya, IndiaFirst Life Insurance Co. Ltd.? Yes No

1. Proposer/ Policy Owner Details (Please fill in details of Life to be Assured if same as Proposer)

1. Full Name (Leave a blank space between First and Last Name)
Dr. Mr. Mrs. Ms. Mx.
Paresh Mehta
Existing IndiaFirst Policy Owner, Kindly enter policy number / client id
Policy No Client ID
Communication Address of the Proposer (Address to which policy document will be dispatched)
16 ratan mansion 1st floor

Room no 5 2nd khetwadi nr

Alankar cinema khetwadi girgao

Mumbai

Maharashtra Pin Code 400004

Mobile* + (91 ) 8779566715 Landline + ( )

Country Code *Receive alerts through SMS andWhatsApp forthis proposal / policy STD/ISD
Email ID*
*Receive communication via e-mail

DOB : 10/07/1997 Gender: Male Female Transgender Nationality: Indian Non Indian

Marital Status : Unmarried Married Widow(er) Divorced Residental Status : Resident NRI PIO

Education : Post Grad Graduate Diploma 12th pass 10th pass Below 10th Illiterate

Occupation : Salaried Professional Self Employed Student Housewife Retired Agriculturist

Others (Please Specify)

Nature of work/duties:

Industry Type : Jewellery Import/ Export Mining Shipping Scrap Dealing Real Estate Agriculture Stock Broking

Others (Please Specify)

Organisation Type : Govt Pvt. Ltd Public Ltd. Partner/ Proprietor Trust HUF Society
Name of the Org./Business : Total Years in Service/ Business

Income Source of Income : Identity Proof (Proposer)

(annual)

PAN : PAN Yes No Address Proof(Proposer) Age Proof(Proposer)

(Proposer) (Please provide Form 60, if PAN is not available) (photocopy Enclosed)

Is this policy self proposed Yes No Relationship with Life to be Assured

Are you a Politically Exposed Person ? 1) Proposer Yes No 2) Life to be Assured Yes No
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.

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 Application No: P03319158

Additional Details - Indicator for Residence / Tax status

(a) Place of birth and Country of birth

(b) Are you a citizen of any other country also (Dual / Multiple) Yes No

(c) Are you a resident (For tax purposes) of any other country other then India Yes No

(d) Do you hold a green card of US or any similar card for any other country Yes No
If answer to any /all of the above is yes, please do fill all the details in the Insurance FATCA Declaration

2. Details of the Life to be Assured (Please fill section 2 only if Life to be Assured is different from Proposer)

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

DOB : Gender: Male Female Transgender Nationality: Indian Non Indian

Marital Status : Unmarried Married Widow(er) Divorced Residental Status : Resident NRI PIO

Education : Post Grad Graduate Diploma 12th pass 10th pass Below 10th Illiterate

Occupation : Salaried Professional Self Employed Student Housewife Retired Agriculturist

Others (Please Specify)

Nature of work/duties: PAN Yes No

(photocopy Enclosed)

PAN : Source of Income : Age Proof (Life Assured)

(Please provide Form 60, if PAN is not available)

Name of the Org./Business : Total Years in Service/ Business Income (Annual)

Additional Details - Indicator for Residence / Tax status

(a) Place of birth and Country of birth

(b) Are you a citizen of any other country also (Dual / Multiple) Yes No

(c) Are you a resident (For tax purposes) of any other country other then India Yes No

(d) Do you hold a green card of US or any similar card for any other country Yes No
If answer to any /all of the above is yes, please do fill all the details in the Insurance FATCA Declaration

3. Nominee/ Appointee Details (To be filled in case life to be assured and proposer are same. Appointee details required only if nominee is a minor)

Nominee Name Percentage Share DOB of Nominee Relationship of Nominee Appointee Name (if applicable) Appointee Relationship with Nominee

4. Plan Details

Policy Term Premium Paying Term Installment Premium Sum Assured

IndiaFirst Life Long Guaranteed Income Plan 10 7 104500 1324000
IndiaFirst Term Rider
IndiaFirst Life Waiver Of Premium Rider
-
Option 1 Option 2 Option 3

Premium Frequency: Single Yearly Half Yearly Quarterly * Monthly (Only ECS/ Direct debit)

#ECS/DD with cancel cheque copy and DD mandate should be verified by bank branch. Renewal Premium Payment Options:1. *Standing Instructions 2. Cheque

Note: IndiaFirst Term Rider is applicable for IndiaFirst MahaJeevan Plan & IndiaFirst Life Long Guaranteed Income Plan. IndiaFirst Life Waiver Of Premium Rider is applicable for IndiaFirst
MahaJeevan Plan, IndiaFirst Life Smart Pay Plan & IndiaFirst Life Long Guaranteed Income Plan.

I would like to fund my future premium with the survival benefit – Yes No (Applicable only for IndiaFirst Life Smart Pay Plan)

(Please select the appropriate option for IndiaFirst Life Little Champ Plan, IndiaFirst Life Guaranteed Monthly Income Plan, IndiaFirst Life Smart Pay Plan, IndiaFirst Life Long Guaranteed
Income Plan or IndiaFirst Life Guaranteed Benefit Plan)

Death Benefit Option Lump Sum Income ( 5 Years 10 Years 15 Years )

For IndiaFirst Life Guaranteed Monthly Income Plan please choose appropriate Gap Year: 0 Year 3 Years 5 Years
(Please select the appropriate option for IndiaFirst Life Little Champ Plan)

Risk Cover Option Death Cover Accidental Death Cover Accidental Disability Cover Comprehensive Cover

Total Payout Option 1) 101% 2) 102% 3) 105% 4) 107% 5) 110% 6) 115% 7) 120% 8) 125%

For IndiaFirst Life Long Guaranteed Income Plan please choose appropriate Income Benefit Frequency Yearly Half Yearly Quarterly Monthly
(Please select the appropriate option for IndiaFirst Life Guaranteed Benefit Plan) If Income Benefit Option is chosen, please mention below details:-
Monthly Income ₹  GAP Period Income Period 0
Benefit Option Lumpsum Benefit Income Benefit (Years)(Years)

Death Benefit Option for IndiaFirst Life Wealth Maximizer Plan, IndiaFirst Money Balance Plan & IndiaFirst Smart Save Plan Lump Sum Income (5 Years)
Systematic Partial Withdrawal option is applicable only for IndiaFirst Life
Systematic Partial Withdrawal Option Yes No If yes 1) Percentage of withdrawal (Between 0% - 25%)
Wealth Maximizer Plan after completion of first 5 policy years.

2) Frequency Yearly Half Yearly Quarterly Monthly 3) From Policy Year to Policy Year
Note: ATBIS is applicable for IndiaFirst Money Balance Plan & IndiaFirst Life Wealth Maximizer Plan. For IndiaFirst Life Wealth Maximizer Plan please select either an investment strategy or the fund options in which you want to invest your premiums.

I. Automatic Trigger Based Investment Strategy (ATBIS) Yes No II. Fund Transfer Strategy Yes No III. Age Based Investment Strategy Yes No

Select only one option from I to III for IndiaFirst Life Wealth Maximizer Plan

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 Application No: P03319158

Funds (Funds total to be 100%)

Equity1*** (ULIF009010910EQUTY1FUND143) Value (ULIF013010910VALUEFUND0143) Liquid1 (ULIF014010910LIQUID1FND143)
Debt1*** (ULIF010010910DEBT01FUND143) Balanced1 (ULIF011010910BALAN1FUND143) Index Tracker (ULIF012010910INDTRAFUND143 ) 0
Equity Elite Opportunities (ULIF020280716EQUELITEOP143) Dynamic Asset Allocation (ULIF015080811DYAALLFUND143)
***Equity1 and Debt1 are the only available fund options under IndiaFirst Money Balance Plan. Liquid 1 fund is not available at inception.
For Fund Transfer Strategy , please select one Equity Oriented Fund and one Debt Oriented Fund.

Note: Direct Debit/ECS declaration: I hereby give my consent to debit my bank account towards the initial premium deposit for my insurance proposal.The first three months premium is to be paid as first
installment for the monthly mode option. Any cash/cheque/DD payment made towards first or renewal premium is deemed to be received by ”IndiaFirst Life Insurance Company Ltd.” only when the same has
been received by any of its offices or its authorised banking partners or collection point and after an official printed receipt is issued by the Company. Cheques must be drawn only in favour of IndiaFirst Life
Insurance Company Ltd. (Application no. for first premium/ policy no. for renewal premium should be written behind the cheque). Note: The collections points/ centers for accepting payment in cash/ cheque/
DD will be as specified by the Company from time to time.

Third Party payment:: I hereby declare that the payment mode as availed by me under my policy belongs to me and I take sole responsibility for the same in respect of any incorrectness of any statement in
this regard.

5. Benefit Payment Mode (Choose any one mode only)

Mode selected will be used by the Company to pay the proposer according to the terms of the plan. If none of the below electronic payout option is chosen, the Company reserves the right to use any alternative
payout option.

ECS Direct Credit (Bank of Baroda & Andhra Bank) NEFT Bank Name:

Account Type Current Savings Branch Name: Bank Account No.:

MICR: (Mandatory for ECS mode) IFSC Code: (Mandatory for NEFT mode)

Customer’s Name as per the Bank Account.:

Please provide a cancelled copy of your cheque if any of the above option is selected
Disclaimer: In case of non credit to my bank account with/without assigning any reasons thereof or if the transaction is delayed or not credited at all for reasons of incomplete/incorrect information, I will not
hold IndiaFirst Life Insurance Co. Ltd. responsible. Further, the Company reserves the right to use any alternative payout option including demand draft/payable at par cheque in spite of opting for the direct
credit option.

6. Life to be Assured’s Family History (Please tick Yes or No)

Have either of your parents or any brothers or sisters suffered from or died due to any of the following conditions: Heart problems, diabetes, stroke, hypertension, raised cholesterol, cancer, or any hereditary
disease? If yes, please give full details below: Yes No

Family Members Age If Alive, Illness, if any Age If Deceased, exact cause of Death

7. Proposer’s Insurance Details (Applicable to minor lives and housewives)

Parent’s/ Husband’s insurance details - Total Sum Assured (₹.)  0

8. Details of life insurance policies held/ proposals applied with life insurance companies (including existing policies with IndiaFirst Life Insurance Co. Ltd.)

Have you ever applied for life insurance policies with IndiaFirst Life Insurance Co. Ltd and with other insurers? Yes No
If yes, please give full details below, with present status and terms of acceptance for all proposals/ policies applied

Name of Life to be Name of the Sum Assured Year of

Policy/ Proposal No. Annual Premium Present Status and Terms of Acceptance
Assured/ Proposer Company including riders Commencement

Standard Rated up Declined

Postponed Lapsed Rejected

Standard Rated up Declined

Postponed Lapsed Rejected

Standard Rated up Declined

Postponed Lapsed Rejected

Standard Rated up Declined

Postponed Lapsed Rejected

Standard Rated up Declined

Postponed Lapsed Rejected

Additional sheets with relevant details signed by the life to be assured may be added if space is insufficient

9. Lifestyle questions and personal medical history of the Life to be Assured (If 'Yes', please encircle the activity/ ailment/ disease)
Non disclosures or misrepresentation of facts will highly impact claim settlement

a. Height in cm: / Feet: 0 inches: 0 Weight in kg:

b. Have you taken part, or do you have plans to take part, in any hazardous/ dangerous activity such as ballooning, mountain cycling, motorbike racing, boxing, gliding,
diving, horse riding, martial arts, motor racing, mountain climbing, parachuting, sailing, skiing, weight lifting, white water rafting, wrestling and/ or flying other than as a fare
paying passenger on a licensed service or any other hazardous/ dangerous activity which is not listed. If yes, please provide details in the special questionnaire which your Yes No
advisor will provide.
c. Are you currently or do you intend to live or travel outside India for more than six months in a financial year? If yes, please provide full details of countries to be visited the
purpose of visit and duration Yes No
d. Have you smoked or used any form of tobacco in the past 12 months? If yes, please indicate in which form:
Cigarettes Beedi Chew Gutka Quantity per day 0 Yes No

e. Do you consume any form of alcohol? If yes, what type? Beer Wine Hard liquor Quantity per day 0 Yes No
f. Are you currently taking any medication or drugs, other than for minor conditions, (e.g. cold and flu), either prescribed or not prescribed by a doctor, or have you suffered
from any illness, disorder, disability or injury during the past 5 y ears which has required any form of medical or specialised examination (including chest x-rays, Yes No
gynecological investigations, pap smear, or blood tests), consultation, hospitalisation or surgery?
g. Do you have any congenital/birth defects, pain or problems in the back, spine, muscles or joint, arthritis, gout, severe injury or other physical disability and have you been
incapable of working/attending the school during the last two years for more than three consecutive days or are you currently incapable of working / attending school? Please Yes No
ignore normal pregnancy

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 Application No: P03319158

h. Do you suffer from or ever had any medical ailments such as diabetes, high blood pressure, cancer, respiratory disease (including asthma), kidney or liver disease, stroke,
any blood disorder, heart problems? Yes No
i. Do you suffer from or ever had any medical ailments such as Hepatitis B or C, or tuberculosis, psychiatric disorder, depression, colitis, or any other stomach problems,
thyroid disorders, reproductive organs, HIV AIDS or a related infection? Yes No
j. Do you suffer from or ever had any medical ailments such as tumor growth, prostrate disorder, disorder of skin or lymph glands, multiple sclerosis, epilepsy, tremor,
numbness, double vision or giddiness, speech defect, paralysis? Yes No

k. Have you ever been advised/ had a surgery or any medical investigations such as X-ray, CT scan, mammogram, pap smear etc? Yes No
l. Have you ever suffered from drug/ narcotics or alcohol addiction or been advised by a doctor to reduce your alcohol/ tobacco consumption? Yes No
m. In the last 3 years, have you been treated, are currently undergoing or have been advised for treatment from a doctor or specialist or undergone any cardiological, radiology
or pathological tests (excluding routine check ups)? Yes No
n. Is your occupation associated with any specific hazards which would render you susceptible to any injury or illness, e.g. chemical factory, mines, explosives, corrosive
chemicals, etc.? Yes No
o. Has your weight altered (Gain/Loss) by more than 5 kgs. in the last 1 years?
If yes, please mention weight gain (in Kgs) 0 or Loss 0 (in Kgs)
Yes No
Reason for Gain / Loss

p. Have you ever been convicted for any Criminal convictions/activities /offences? Yes No
q. Have you ever been suffered/suffering Any other disease/disorder not mentioned above ? Yes No

10. If you have answered Yes, to any of the questions between 9(f) and 9(q) please provide details here

Question no. For question No. 9(f) to 9(q) provide complete details including health condition, date of diagnosis, treatment prescribed, name/ address of doctor, if applicable

11. For Female Life to be Assured only

a. Are you pregnant at present? Yes No If yes duration in weeks b. Date of last delivery

c. Please state any complications during pregnancy?

12. Insurance Repository

Existing e - Insurance Account (e-IA) holder, please provide the e IA and IR name

E IA Number

IR Name

Open New e - Insurance Account - Please choose the repository from the below

IR Code IR Name
01. NSDL Database Management Limited
02. Central Insurance Repository Limited
04. Karvy Insurance Repository Limited
05. CAMS Repository Service Limited

Do you need a physical copy of Policy Document? Yes No

13. Declaration by Proposer/ Life to be Assured

I / we have understood the questions in the proposal form and I / we have answered them truthfully, completely and correctly. I / we further declare that I / we have not withheld any material fact or
information which may affect the decision of IndiaFirst Life Insurance Company Limited (Hereafter called the “Company”) in underwriting the risk, and the information provided by me / us in the proposal
form, the supplementary documents and information provided to the medical examiner in case of being medically examined will form the basis of the contract between me/us and the Company and in case of
fraud, misrepresentation and suppression of material facts the policy contract shall be treated in accordance with the Sec 45 of Insurance Act,1938 as amended from time to time. I / we hereby authorize and
direct any doctor, hospital, or employer (past and present) to disclose to the Company any information relating to my present state of health, past health history and nature of work performed by me / us. I / we
undertake to undergo all medicals as may be required by the Company to assess the risk and grant the insurance. I / we further agree that if after the date of submission of the proposal but before the issuance of
policy (i) there is an adverse change in my / us occupation, financial condition, health condition which will affect the decision of the Company in underwriting risk or (ii) if a proposal for assurance or an
application for revival of the policy on my / our life or the life to be assured made to any insurer is withdrawn or dropped, deferred, declined or accepted at an increased premium or subject to a lien or on terms
other than as proposed, I / we shall forthwith intimate the same to the Company in writing. Failure to do this on my / our part may render this assurance invalid and the policy will be dealt in accordance with
section 45 of the Insurance Act, 1938 as amended from time to time. I / we understand that the cover applied for under this application will commence after approval of my application and receipt of the
required premium by the Company. I / we, hereby declare thatthe premium have not been generated from proceeds of any criminal activities / offences listed in the Prevention of Money Laundering Act 2002 or
under any other applicable law. I understand that in case of withdrawal of this application by me post undergoing medicals or part thereof, the Company shall return the premium deposit after deducting the
expenses incurred on the medical test/examination, if any.
I/we hereby declare that the Date of Birth, Health related questions and Financial status of Life to be Assured mentioned in proposal form is correct and true to my knowledge. In case the
information disclosed found to be incorrect or misrepresented claim will be treated in accordance with the Sec 45 of Insurance Act 1938 as amended from time to time.
AML-eKYC declaration:I hereby give my unconditional consent to the Company to carry out due diligence in respect of information, as provided by me in the proposal form, including AML-eKYC
verification, andalso to store/share the data/information with government agencies/ statutory authorities/ entities as authorized by the regulator – IRDAI/ Life counsel/any other entity for necessary verification
purposes and/or policy servicing purpose.

Life to be Assured’s Signature or Thumb Impression Proposer’s Signature or Thumb Impression

Name: Paresh Mehta Place: Date: 15/12/2021 Name: Paresh Mehta Place: Date: 15/12/2021

Witness’s Signature or Thumb Impression Name: Address:

Signature authentication (Single factor authentication): An OTP authentication number has been sent on your registered mobile number. By feeding in the said number in the system, you hereby
unconditionally and absolutely acknowledge the above declaration in its entirety and the same would create a legally binding agreement between the Company and You.
Section 41 of Insurance Act 1938, as amended from time to time: 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 prospectus or tables of the insurer. Any person making default in

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 Application No: P03319158

complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
Extract of Section 45 of the Insurance Act, 1938, as amended from time to time: No policy of life insurance shall be called into question on any ground whatsoever after the expiry of three years from the
date of policy. A policy of life insurance may be called into question at anytime within three years from the date of policy, on the ground of fraud or 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. The insurer shall have to
communicate in writing to the insured or legal representatives or nominees or assignees of the insured, the grounds and materials on which such decision is based. No insurer shall repudiate a life insurance
policy on the ground of fraud if the insured can prove that the misstatement or suppression of 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 misstatement or suppression are within the knowledge of the insurer. In case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive. In case of
repudiation of the policy on the ground of misstatement or suppression of a material fact and not on the grounds of fraud, the premiums collected on the policy till the date of repudiation shall be paid. 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 calledin 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. For complete details of the section and the definition of 'date of policy', please refer Section 45 of the
Insurance Act, 1938, as amended from time to time.

14. Declaration For Signing In Vernacular Or For Uneducated Persons

1. Vernacular Declaration by the person filling in the form (In case form is filled up / signed in a language different from that of the Proposal Form)
I do hereby state that I have read out and explained the contents of the proposal form and all other documents incidental to availing the Insurance Policy from IndiaFirst Life Insurance Co. Ltd to the
proposer/life assured and he/she have understood the same. I declare that whatever I have stated herein above is true and correct to the best of my knowledge and belief.
Name of the Declarant : Signature : Relation with the Life Assured/Proposer

Address of the Declarant :

Note: The Declarant identity should be easily established and he/she should not be connected to insurer in any capacity
I certify that the product applied for by me and the contents of the proposal form have been clearly explained to me and I have fully understood them. I further certify that the replies in the proposal form have
been recorded as per the information provided by me.

Signature or thumb impression of the person whose life is proposed to be assured :

2. In case the Life Assured/Proposer is illiterate, his/her thumb impression should be attested by a person of standing whose identity can easily be established, but unconnected with the insurer and this
declaration should be made by him. “I hereby declare that I have fully explained the above questions and contents of the proposal form to the life assured / proposer in language,
and that the life assured / proposer has affixed the thumb impression above after fully understanding the contents thereof.”
Name of the Declarant : Signature : Relation with the Life Assured/Proposer

Address of the Declarant :

15. Occupation Details of the Life to be Assured

(Please tick one of the occupation types that best describes your current occupation as chosen in S.No 1 or 2)

Code Occupation Types Code Occupation Types

01 Salaried - administrative employees, clerk, executive, accountant 16 Electricity Line Worker
Professionals - doctor, chartered accountant / advocate- lawyer / teacher- lecturer,
02 17 Explosives handler - demolition experts
professors
03 Salesman - including counter sales staff 18 Fireman
04 Retail / whole sale shop owner, commission agents 19 Fisherman
05 Retired / pensioner 20 Hotel industry other than 5 star
06 Student 21 Merchant navy others
07 House wife 22 Mining, coal miner, mining engineers
Agriculture - labourer, cleaner, maintenance workers, gardener, hawker, mill worker,
08 23 Oil Rig worker
porter / coolie
09 Armed force personnel (military service) 24 Police
10 Aviation - includes all pilots 25 Well sinker / Bore well drillers
11 Blacksmith, boiler worker, furnace workers, welding workers, machine operators 26 Print / media involved in war
12 Weaver, lift operators, domestic servants, mason, mechanic 27 Professional sports person
13 Construction / building worker 28 Security guard
14 Diver - water, deep sea 29 Others (None of the above)
15 Driver - ambulance, armoured vehicle, lorry etc

16. Intermediary details

Name of the Intermediary BANK OF BARODA License Number SC1003

(Applicable for all channels except Individual Agents)

Signature of the Agent / Specified Agents Stamp of the Intermediary

Name of the Agent / Specified Agents BETHA JYOTSNA License Code SP0004037439

17. Know Your Customer Certificate Issued by Bank

We hereby confirm that holds Savings/Current/Fixed Deposit Loan Account no. and Bank Customer ID
with our bank. We confirm that we have obtained the necessary documentary evidence to establish the identity and address of the customer as mentioned by him/ her in this
proposal form, as per the “Know Your Customer” (KYC) norms for banks.
Signature of Authorized Signatory from Bank:

Name of Authorized Signatory from Bank:

Name of the Bank Branch: ZAVERI BAZAR Bank Seal

Aforementioned details can be used by the company to pay the proposer according to the terms of the plan. Payment options (cheque will be used if none of the below electronic payout option is chosen).
Further, the company reserves the right to use any alternative payout option including demand draft/payable at par cheque in spite of option for Direct Credit

• UIN for IndiaFirst Money Balance Plan 143L017V05 • UIN for IndiaFirst Smart Save Plan 143L010V04 • UIN for IndiaFirst MahaJeevan Plan 143N018V05
• UIN for IndiaFirst Term Rider 143B001V02 • UIN for IndiaFirst Simple Benefit Plan 143N019V03 • UIN for IndiaFirst Life Plan 143N007V02

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 Application No: P03319158

• UIN for IndiaFirst Anytime Plan 143N009V02 • UIN for IndiaFirst Life Wealth Maximizer Plan • UIN for IndiaFirst Life Cash Back Plan 143N024V03
• UIN for IndiaFirst Life Little Champ Plan 143N035V01 143L029V03 • UIN for IndiaFirst Life Smart Pay Plan 143N051V02
• UIN for IndiaFirst Life Waiver of Premium Rider • UIN for IndiaFirst Life Guaranteed Monthly Income Plan
143B017V01 143N047V01
• UIN for IndiaFirst Life Guaranteed Benefit Plan • UIN for IndiaFirst Life Long Guaranteed Income Plan
143N056V04 143N054V02

IndiaFirst Life Insurance Company Ltd.,12th and 13th Floor, North[C] Wing,
Tel:+91 22 6165 8700 Fax:+91 22 6857 0600 Toll Free:1800-209-8700
Tower 4, Nesco IT Park, Nesco Center,Western Express Highway, Goregaon (East),
Mumbai – 400063, e-mail:[email protected] Website:www.indiafirstlife.com
IRDAI Regd. No. 143 I CIN: U66010MH2008PLC183679.